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A  MANUAL  AND  ATLAS 

OF 

ORTHOPEDIC  SURGERY. 


YOUNG. 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualatlasofortOOyoun 


A  MANUAL  AND  ATLAS 


ORTHOPEDIC  SURGERY 


Including  the  History,  Etiology,  Path- 
ology, Diagnosis,  Prognosis,  Prophy- 
laxis,  AND    Treatment    of    Deformities 


JAMES   K.  YOUNG,  M.D. 


S'     ORTHOPEDIC     SURGERY,     UNIVERSITY     OF     PENNSYLVANIA;     PROFESSOR     OF     ORTHOPEDIC     SURGERY, 

-llA    POLYCLINIC;    CLINICAL    PROFESSOR    OF    ORTHOPEDIC    SURGERY,    WOMEN'S    MEDICAL    COLLEGE     OF 

PENNSYLVANIA;    FELLOW    OF    THE   COLLEGE    OF    PHYSICIANS   OF   PHILADELPHIA;    FELLOW   OF 

THE     PHILADELPHIA    ACADEMY    OF     SURGERY;      FELLOW    OF    THE     AMERICAN 

ORTHOPEDIC    ASSOCIATION;     MEMBER     OF    THE    AMERICAN 

MEDICAL    ASSOCIATION,     ETC. 


ILLUSTRATED  WITH  OVER  SEVEN  HUN- 
DRED PHOTOGRAPHS  AND  LINE  DRAW- 
INGS,   mostly    FROM    ORIGINAL    SOURCES 


PHILADELPHIA 

BLAKISTON'S    SON     &    CO 

I  O  I  2     WALNUT     STREET 
190^ 


Copyright,  1905,  by  P.  Blakiston's    Son   &  Co. 


LfKWv "  *Q+^cJL<,-,.  -y- 


ELECTROTYPeRS   . 


PREFACE. 


This  Manual  and  Atlas  of  Orthopedic  Surgery  is  the  result  of  an  experience 
of  twenty  years  devoted  to  the  study  of  this  subject  in  the  dispensaries  and  wards 
of  the  large  hospitals  of  Philadelphia  and  elsewhere.  During  the  preparation 
of  the  work  every  available  treatise  upon  the  subject  has  been  consulted,  in  the 
effort  to  present  it  in  such  a  manner  as  to  be  of  practical  use  to  the  general  prac- 
titioner as  well  as  to  the  student  of  medicine.  The  work  has  been  divided  into 
two  parts,  the  first  devoted  to  General  Orthopedic  Surgery  and  the  second  to 
Special  Orthopedic  Surgery,  in  conformity  with  the  plan  adopted  by  the  best 
Continental  writers.  The  chief  object  in  view  has  been  to  include  in  the  work 
everything  within  the  scope  of  orthopedic  surgery,  without  encroaching  upon 
the  field  of  general  surgery  or  any  other  specialties. 

The  writer  is  indebted  to  Professor  DeForest  Willard,  of  the  University 
of  Pennsylvania,  for  many  acts  of  kindness  and  for  many  excellent  opportun- 
ities of  studying  this  important  subject  of  deformities. 

Great  care  has  been  taken  in  selecting  the  illustrations,  which  have  been 
chosen  from  a  large  collection  obtained  from  many  sources.  The  art  photo- 
graphs were  kindly  loaned  from  the  very  valuable  collection  of  Hudson  Chap- 
man, of  Philadelphia. 

He  is  also  indebted  to  his  foreign  confreres  for  the  loan  of  valuable  photo- 
graphs of  rare  and  severe  deformities,  especially  to  Robert  Jones,  of  Liverpool, 
and  Professors  Lange,  of  Munich,  Heussner,  of  Bremen,  Schanz,  of  Dresden, 
and  Hovorka,  of  Vienna. 

He  also  acknowledges  his  indebtedness  to  Dr.  E.  H.  Nichols,  of  Boston, 
Dr.  Joseph  N.  Spellissy,  of  Philadelphia,  and  Dr.  Wallace  Blanchard,  of  Chicago, 
for  timely  photographs. 

The  Mutter  Museum  of  the  Philadelphia  College  of  Physicians,  and  the 
Wistar  Institute  of  Anatomy,  through  the  kindness  of  Dr.  Greenway,  and  also 
the  Army  Medical  Museum,  have  all  contributed  generously  toward  the  illus- 
trations, adding  materially  to  the  completeness  of  this  part  of  the  book.  The 
:x:-ray  photogi'aphs  are  from  the  valuable  collections  of  Professor  Goodspeed 
and  Dr.  Kassabian.  Permission  has  been  kindly  accorded  by  "Medicine"  for 
the  use  of  certain  t}'pical  illustrations  of  scoliosis,  which  had  been  previously 


viii  PREFACE. 

published  by  the  writer  in  that  journal.  To  James  F.  Wood,  of  Philadelphia, 
the  vvork  owes  much  of  its  excellence  as  to  photographic  technicjue. 

The  statistical  tables  upon  Tuberculous  Joint  Disease  were  prepared  by 
Dr.  Harold  Wood,  and  Dr.  Thomas  H.  Evans  has  contributed  the  Italian  and 
Spanish  synonyms. 

The  ^vriter  is  also  indebted  to  Dr.  James  A.  Kelly  for  valuable  assistance 
in  the  preparation  of  the  text,  particularly  in  the  section  upon  Tuberculous 
Joint  Disease. 


TABLE  OF  CONTENTS. 


PART  I. 
GENERAL  ORTHOPEDIC  SURGERY. 


CHAPTER  I. 

PAGE. 

INTRODUCTION  AND  HISTORY, 1-14 

Precontinental  Period. — Continental  and  Early  English  Period. — Nineteenth 
Century. — American  History. 

CHAPTER  II. 

GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY, 15-89 

Congenital  Deformity. — Heredity. — Intrauterine  Pressure. — Pre-natal  Disease. 
Arrest  or  Defect  of  Development. — Acquired  Deformity. — Traumatic  Deformi- 
ties.— Static  or  Habitual  Deformities. — Vestmentary  Deformities. — Constitu- 
tional Deformities. — Trauma  as  an  Etiologic  Factor. — Contractures  and  Anky- 
losis.— General  Etiology,  Pathology,  and  Treatment  of  Tuberculous  Joint 
Disease. 

CHAPTER  III. 
GENERAL  CLASSIFICATION  AND  GENERAL  STATISTICS  OF  DEFORMITY,       90-93 
Arrangement  of   Orthopedic  Affections. — General   Statistics  of   Deformity. — 
Table  of  Diseases  Belonging  to  the  Department  of  Orthopedic  Surgery. — 
Relative  Frequency  of  Deformities. — Statistics  upon  the  Subject  of  Tuberculosis. 

CHAPTER  IV. 
GENERAL  SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  DEFORMITY,. .     96-117 
General  Subject  of  Symptoms.— The  Effect  of  Deformity  upon  the  Intellect.— 
Attitude   in  Deformity. — Diagnosis  of  Deformity. — Bacteriology. — Mensura- 
tion.— Prognosis. 

CHAPTER  V. 

PROPHYLAXIS  AND    GENERAL   TREATMENT, 118-17S 

Diet. — Sunhght. — Change  of  Residence. — Medical  Treatment. — Electricity. — 
Gymnastics. — Mechanical  Gymnastics. — Massage. — Heat. — Local  Treatment. 
— Orthopedic  Apparatus  and  Apphances. — Corrective  Apparatus. — Orthopedic 
Bandages,  Sphnts,  etc. — Adhesive  Plaster,  Plaster-of-Paris,  Felt,  Celluloid, 
etc. — Artificial  Limbs. — Orthopedic  Operations. — Forcible  Correction. — Osteo- 
clasy. 

CHAPTER  VI. 

TENOTOMY, 176-19S 

Technic. — CompHcations    of    Tenotomy. — After-treatment    of    Tenotomy. — 


X  TABLE  OF  CONTEXTS. 

PAGE 

Division  of  Individual  Tendons. — Tendon  Shortening. — Transplantation  of 
Tendons. — Aponeurotomy. — Myotomy. — Neurotomy.— Neurectomy. — Neuror- 
rhaphy, or  Nerve  Suturing  (Neuroplasty;  Nen'e  Anastomosis;  Transplantation 
of  Nerves). 

CHAPTER  VH. 

OSTEOTOMY, 199-206 

Technic. — Vertical,  Longitudinal,  or  Oblique  Osteotomy. — Chrondrectomy 
and  Chrondrotom}-. — Arthrodesis. — Erasions. — Articular  Resections. — Ampu- 
tations. 


PART   II. 

SPECIAL  ORTHOPEDIC  SURGERY. 


CHAPTER  I. 

POTT'S  DISEASE  OF  THE  SPINE, 207-271 

Histor}-. — Synonyms. — Frequenc}-. — Relative  Frequency. — Localization  of  the 
Disease. — Etiology. — Patholog}^ — Abscess. — Symptomatology. — ]M  u  s  c  u  1  a  r  . 
Spasm. — Attitude. — Pain. — Breath  Catch. — Deformity. — Paraplegia. — Diag- 
nosis.— Differential  Diagnosis. — Progress  and  Prognosis. — Treatment. — Re- 
cumbency.— Suspension. — Mechanical  Treatment. — Correction  of  the  Defor- 
mity.— Gradual  Reduction. — Spine  Braces. — Treatment  of  Caries. — Treatment 
of  Abscesses  (Expectant). — Operative  Methods. — Treatment  of  Paraplegia. 

CH.\PTER  II. 

NON-TUBERCULOUS  DISEASES  OF  THE  SPINE, 272-294 

Kj-phosis. — Synonyms. — Adolescent  K}'phosis. — Round  Shoulders. — Muscular 
Kj-phosis. — Rachitic  K}^hosis. — Chondrodystrophia. — Osteitis  and  Spondyl- 
itis Deformans. — Scorbutic  Spondylitis. — TT."phoid  Spine. — S}^hilis  of  the 
Spine. — Traumatic  Spondylitis. — Infectious  Diseases  of  the  Spine. — Acrome- 
galy.— H}'pertrophic  PuLmonar}'  Osteoarthropathy. — Malignant  Disease  of  the 
Spine. — Sarcoma  of  the  Spine. — Lordosis. — Synonyms. — Compensatory. — 
Paralytic. — Pathologic. — SpondyloMsthesis. — Deformities  of  the  Thora.x. — Con- 
genital.— Funnel  Chest. — Acquired. — Flat  Chest. — Pigeon  Breast. — Prognosis. 
— Treatment. 

CHAPTER  III. 

SACRO-ILLA.C  DISEASE, 295-300 

Synonyms. — Etiolog}-. — Patholog3^ — Symptoms. — Diagnosis. — P  r  o  g  n  o  s  i  s . — 
Treatment. 

CHAPTER  IV. 

HIP-JOINT  DISEASE, 301-372 

Synonyms. — Frequency. — Etiology. — Pathology. — Symptoms. — A  b  s  c  e  s  s. — 
First  Stage. — Second  Stage. — Third  Stage. — Destruction. — Hip  Disease  in  the 


TABLE  OF  CONTENTS.  xi 

PAGE. 

Adult. — Double  Hip  Disease. — Remissions. — Diagnosis. — Atrophy. — Mensura- 
tion.— Lameness. — Attitude. — Pain. — Swelling. — Differential  Diagnosis. — 
Prognosis. — Relapse. — Causes  of  Death. — Amount  of  Deformity. — Treatment. 
— Recumbency. — Fixation. — Traction. — Protective  Splints  in  Convalescence. — 
Treatment  of  Complications. — Treatment  of  Sinuses. — Correction  of  Deform- 
ity.— Multiple  Myotomy  and  Tenotomy. — Brisement  Force. — Osteotomy. — 
Operative  Treatment. — Aspiration. — Trephining. — Incision. — Exploratory  In- 
cision, Erasion,  and  Drainage. — Excision. — Amputation. — Treatment  of  Double 
Hip  Disease. — Treatment  of  Other  Forms. 

CHAPTER  V. 

NON-TUBERCULOUS  DISEASES  OF  THE  HIP, 373-404 

Traumatism. — Synovitis  of  the  Hip. — Chronic  Serosynovitis  of  the  Hip. — Acute 
Arthritis  of  the  Hip-joint. — .Arthritis  Deformans  of  the  Hip-joint. — Neuropatliic 
Affections  of  the  Hip-joint. — Malignant  Disease  of  the  Hip. — Coxa  Vara. — 
Coxa  Valga. — Spontaneous  Dislocation. — Fracture  of  the  Neck  of  the  Femur  in 
Children. — Bursitis. — Foreign  Bodies  in  the  Hip-joint. 

CHAPTER  VL 

DISEASES  OF  THE  KPfEE-JOINT, 405-439 

Synonyms. — Etiology. — Pathology. — Symptoms. — First  Stage. — Second  Stage. 
— Third  Stage. — Recovery. — Destruction. — Diagnosis. — Differential  Diagnosis. 
— Prognosis. — Treatment. — Constitutional  Treatment. — Mechanical  Treat- 
ment.— Supplementary  Treatment. — Treatment  of  Complications. — Deform- 
ity and  Abscess. — Operative  Treatment. — Arthrectomy. — Resection. — Ampu- 
tation.— Mortality. — Resume. 

CHAPTER  VII. 

NON-TUBERCULOUS  KNEE-JOINT  DISEASE, 440-460 

Acute  Serous  Synovitis. — Chronic  Serous  Synovitis. — Acute  Suppurative 
Arthritis. — Prepatellar  Bursitis. — Chronic  Prepatellar  Bursitis. — Suppiurati^-e 
Prepatellar  Biursitis. — Pretibial  Bursitis. — Enlargement  and  Fracture  of  the 
Tibial  Tubercle. — PopUteal  Bursas  and  Cysts. — Loose  Bodies  in  the  Knee- 
joint. — Dislocation  of  the  Semilunar  Cartilages. — Dislocation  of  the  Patella. — 
Rudimentary  Patella. — Snapping  Knee. — Elongation  of  the  Patellar  Tendon. — 
Rupture  of  the  Quadriceps  Extensor  and  Patellar  Tendons. 

CHAPTER  \TII. 

TUBERCULOUS  DISEASE  OF   THE   ANKLE-JOINT  AND   TARSUS, 461-469 

Etiology. — Pathology. — Statistics. — Symptoms. — Diagnosis. — P  r  o  g  n  o  s  i  s. — 
Treatment. — Conservative  Treatment. — Operative  Treatment. — Tuberculous 
Disease  of  the  Tarsus. — Treatment. 

CHAPTER  IX. 

NON-TUBERCULOUS    DISEASES   OF   THE  ANKLE-JOINT, 470-473 

Acute  Sprain  of  the  Ankle-joint. — Chronic  Sprain  of  the  Ankle-joint. — Teno- 
synovitis. 


xii  TABLE  OF  CONTENTS. 

CHAPTER  X.  '•"^• 

TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT, 474-477 

Statistics. — Pathology. — Symptoms.  —  Diagnosis.  —  Prognosis.  —  Treatment.  — 
Rest,  Fixation,  and  Protection. — Abscess. — Amputation. 

CHAPTER  XI. 

NON-TUBERCULOUS  DISEASES  OF  THE  SHOULDER-JOINT, 478-487 

Acute  Subdeltoid  Bursitis. — Chronic  Subdeltoid  Bursitis. — Tuberculous  Sub- 
deltoid Bursitis. — Suppurative  Subdeltoid  Biu-sitis. — Acromial  Bursitis. — Loose 
Shoulder-joint. — Recurrent  Dislocation  of  the  Shoulder. — Obstetric  Paralysis. — 
Congenital  Elevation  of  the  Scapula. — Congenital  Absence  of  the  Clavicle. — 
Rupture  of  the  Biceps  Muscle. 

CHAPTER  XII. 

TUBERCULOUS  DISEASE  OF  THE  ELBOW-JOINT, 488-494 

Statistics. — Pathology.' — Symptoms. — Prognosis. — Treatment.  —  Constitutional 
Treatment. — Resection. 

CHAPTER  XIII. 

NON-TUBERCULOUS  DISEASES  OF  THE  ELBOW-JOINT, 495-499 

Free  Bodies  in  the  Elbow-joint. — Cubitus  Varus  and  Valgus. — Olecranon 
Bursitis. 

CHAPTER  XIV. 

TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT, 500-504 

Statistics. — Pathology. —  Symptoms.  —  Diagnosis.  — Prognosis.  — Treatment.  — 
Conservative  Treatment. — Operative  Treatment. — Tuberculous  Disease  of  the 
Metacarpals  and  Phalanges. — Synonym. — Symptoms. — Treatment. 

CHAPTER  XV. 

NON-TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT, 505-511 

Tenosynovitis. — Ganglion. — Sprain  of  the  Wrist. — Acute. — Chronic. 

CHAPTER  XVI. 

NON-TUBERCULOUS  JOINT  DISEASES, 512-538 

Infectious  Osteomyelitis. — Synovitis. — Acute  Serous  Synovitis. — Chronic  Serous 
Synovitis. — Intermittent  Joint  Hydrops. — Trauma  as  an  Etiologic  Factor 
in  Joint  Disease. — Traumatic  Arthritis. — Suppurative  Arthritis. — S3'philitic 
Joint  Disease. — Gonorrheal  Arthritis. — Acute  Articular  Rheumatism. — Gout. — 
Hemophilia. — Scorbutus. 

CHAPTER  XVII. 

LATERAL  CURVATURE  OF  THE  SPINE, 539-602 

Synonyms. — Frequency. — Etiology. — Habit. — Static. — Professional. — P  a  t  h  o- 
logic. — Pathology. — Clinical  History  and  Symptomatology. — Diagnosis. — Men- 
suration and  Recording  Methods. — Diagnosis  in  Individual  Forms. — Differen- 
tial Diagnosis. — Progress  and  Prognosis. — Prophylaxis. — Treatment. — Correc- 
tion of  Deformity. — Gymnastics. — Massage. — Mechanical  Correction. — Cor- 
recting Machines. — Treatment  of  Fixed  and  Flexible  Curves. 


TABLE  OF  CONTENTS.  xiii 

CHAPTER  XVIII.  PAGE, 

INFANTILE  SPINAL  PARALYSIS, 603-646 

Synonyms. — Etiology. — Pathology. — Symptoms. — Deformities  of  the  Upper 
Extremity. — Deformities  of  the  Lower  Extremity. — Deformities  of  the  Trunk. — 
Diagnosis. — Electric  Reaction  of  the  Muscles. — Differential  Diagnosis. — Prog- 
nosis.— Prophylaxis. — Treatment. — Medical  Treatment. — Massage  and  Mani- 
pulations.— Mechanical  Treatment. — Operative  Treatment. — Tenotomy. — 
Tendon  Shortening. — Transplantation  of  Muscles  and  Tendons. — Aponeurot- 
omy. — Resection. — Neural  Anastomosis. — Excision. — Arthrodesis. — Amputa- 
tion.— Treatment  after  Operation. 

CHAPTER  XIX. 

INFANTILE  CEREBRAL  PALSIES, 647-670 

Etiology. — Infantile  Hemiplegia. — Bilateral  Spastic  Hemiplegia. — Spastic  Para- 
plegia.— Cerebral  Palsies. — Diagnosis. — Differential  Diagnosis. — Prognosis. — 
Treatment. — Conservative  Treatment. — Circumcision. — Tenotomy. — Tendon 
Grafting. — Craniectomy  and  Asexualization. 

CHAPTER  XX. 

OTHER  PARALYSES, 671-686 

Pseudohypertrophic  Muscular  Paralysis. — Progressive  Muscular  Atrophy. — 
Hereditary  Ataxia. — Peripheral  Palsies. — Spina  Bifida  Paralysis. — Pressure 
Palsies. 

CHAPTER  XXI. 

TORTICOLLIS, 687-698 

Synonyms. — Frequency.  —  Etiology.  —  Congenital.  — Acquired. — Pathology.  — 
Symptomatology. — Diagnosis. — Prognosis. — Treatment.  —  Therapeutic. — Me- 
chanical.— Operative. — Post-operative  Treatment. — Nerve  Operations. 

CHAPTER  XXII. 

NEUROMIMESIS, 699-702 

Svnonvms. — Frequency. — Etiology. — Symptoms. — Paralyses. — Spastic  C  o  n  - 
tractions. — Joint    Disease. — Diagnosis. — Treatment. 

CHAPTER  XXIII. 

NEUROPATHIC  AFFECTIONS  OF  JOINTS, 703-710 

Charcot's  Disease. — Syringomyelia. 

CHAPTER  XXIV. 

UNILATERAL  DEVELOPMENT, 711-714 

Etiology. — S3fmptoms. — Diagnosis. — Treatment. 

CHAPTER  XXV. 

RICKETS;  KNOCK-KNEE;  BOW-LEGS, 71S-746 

Rickets. — Synonyms. — Etiology. — Intrauterine  Rickets. — Infantile  Rickets. — 
Adolescent  Rickets. — Senile  Rickets. — Pathology. — Symptoms. — Incubation. — 
Deformation. — Recovery. — CompHcations. — Prognosis. — Treatment. — M  e  d  i- 


xiv  TABLE  OF  CONTENTS. 

PAGE. 

cal  Treatment. — Operative  Treatment. — Knock-knee. — Synonyms. — Occur- 
rence.— Etiology. — Pathology. — Symptoms. — Diagnosis. — Prognosis. — T  r  e  a  t- 
ment. — Hygienic  Treatment. — Mechanical  Treatment. — Operative  Treatment. 
— Tenotomy. — Forcible  Manual  Straightening. — Osteotomy. — Osteoclasis. — 
Bow-legs. — Synonyms. — Varieties. —  Etiology. — Symptoms. —  Diagnosis.  — 
Prognosis. — Treatment. — Hygienic  Treatment. — Mechanical  Treatment. — 
Operative  Treatment. — Osteotomy. — Osteoclasis. — Anterior  Bow-legs. — Me- 
chanical Treatment. — Operative  Treatment. — Forcible  Fractures. — Osteoclasis. 
— Osteotomy. 

CHAPTER  XXVI. 

OTHER  DEFORMING  DISEASES  OF  THE  BONES, 747-758 

Tardy  Hereditary  SyphiHs  of  the  Bones. — Osteomalacia. — Osteitis  Deformans. 
— Secondary  Hypertrophic  Osteo-arthropathy. — Arthritis  Deformans. — Spon- 
dylitis Deformans,  or  Rheumatism  of  the  Spine. 

CHAPTER  XXVII. 

TALIPES,  OR  CLUB-FOOT, 759-822 

Synonyms. — Anatomy  of  the  Foot. — Varieties. — Relative  Frequency. — Etiology. 
— Symptoms. — Varieties  Especially  Considered. — Talipes  Varus. — Talipes  Val- 
gus.— Congenital  Valgus. — Acquired  Valgus. — Pes  Valgus  Acquisitus. — Pes 
Valgus  Paralytica. — TaHpes  Equinus. — Talipes  Calcaneus. — Artificial  Calcan- 
eus.— Other  Forms  of  Club-foot. — Pes  Cavus. — Pes  Planus. — Non-deforming 
Club-foot. — Neuromimesis  of  Club-foot. — Compound  Forms  of  Club-foot. — 
Talipes  Equino-varus. — Congenital  Equino-varus. — Paralytic  Equino-varus. — 
Talipes  Equino-valgus. — Talipes  Calcaneo-varus. — Talipes  Calcaneo-valgus. — 
Diagnosis. — Prognosis. — Treatment. — Manipulations. — Massage  and  Electri- 
city.— Corrective  Apparatus. — Operative  Treatment. — Tenotomy. — Syndes- 
motomy. — Myotomy. — Tarsectomy  and  Tarsotomy. — Astragalectomy. — Brise- 
ment  Force.^ — Open  Incision. — Amputation. — Treatment  of  Special  Varieties. 

CHAPTER  XXVIII. 

OTHER  AFFECTIONS  OF  THE  FEET, 823-837 

Metatarsalgia.  — Pronation. — Sprains.  —  Hammer-toe. — Clawfoot.  —  Displace- 
ment of  the  Toes. — Lateral  Deviations  of  the  Toes. — Hallux  Valgus. — Hallux 
Varus. — Hallux  Rigidus. — Hallux  Metatarsus. — Achillodynia. — Retro-calcaneal 
Bursitis. — Painful  Heel. — E.xostoses  of  the  Tarsal  Bones. — Erythromelalgia. — • 
Pododynia. — Plantalgia. 

CH.APTER  XXIX. 

CONGENITAL   DISLOCATIONS   OF  THE  HIP,  KNEE,   SHOULDER,  AND 

ELBOW, 838-882 

Frequency. — Etiology. — Heredity. — The  Theory  of  Mechanical  Intrauterine 
Pressure,  or  Traumatism. — Obstetric  Dislocations. — The  Theory  of  the  Pre- 
natal Disease. — The  Theory  of  Arrest  or  Defect  of  Development. — Pathology. — 
At  Birth. — Head  of  the  Femur. — Round  Ligament. — Capsule. — Muscles. — 
Pelvis. — ^In  Children  Who  Have  Walked. — Acetabulum. — Head  of  the  Femur. — 
Neck.- — Capsule. — Ligamentum  Teres. — Muscles. — In  Adults. — Head  of  the 


TABLE  OF  CONTENTS.  xv 

PAGE. 

Femur. — Capsule. — Muscles. — Pelvis. — Symptoms. — Diagnosis. — Prognosis. — 
Treatment. — Treatment  by  Extension  and  Apparatus. — Treatment  by  Forcible 
Reduction. — The  Method  of  Pad. — The  Method  of  Lorenz. — The  Method  of 
Hoffa. — Mechanical  Reduction. — Operative  Methods  Other  Than  Bloodless. — 
Tenotomy. — Resection  or  Decapitation  of  the  Femur. — Axthrotomy,  or  the 
Formation  of  a  New  Articular  Cavity. — Osteotomy. — Congenital  Dislocation  of 
the  Knee. — Congenital  Dislocation  of  the  Shoulder. — Sj'mptoms. — Diagnosis. — 
Treatment. — Congenital  Dislocation  of  the  Elbow. 

CHAPTER  XXX. 

PERVERTED  DEVELOPMENT, 8S3-903 

Club-hand.  —  Synonyms.  — Etiology.  —  Symptoms. — Treatment. —  Deformities 
of  the  Fingers  and  Toes. — Polydactylism. — Congenital  Deficiencies  or  Ectro- 
dactyhsms. — Lobster-claw, — Congenital  Union,  or  Webbed  Fingers  and  Toes. — 
Hypertrophy  of  the  Fingers  and  Toes. — Congenital  Contraction  of  the  Fingers 
and  Toes. — Congenital  Contraction  of  the  Fingers. — Dupuytren's  Contraction. 
— Synonyms. — Trigger-finger. — Mallet-finger. — Congenital  Tumors  of  the 
Fingers  and  Toes. — Congenital  Deficiency  of  Parts. — Etiology. — Treatment. 

CHAPTER  XXXI. 

ACCIDENT  OR  TRAUMATISM, 904-919 

Dislocation  of  Tendons. — Dislocation  of  Cartilage. — Diastasis. — Irreducible 
Dislocations  of  Articulations. — Diagnosis. — Treatment. — Arthrotomy. — Resec- 
tion.— Displacement  of  the  Sacrum. — Ununited  Fractures. — Rupture  of  Muscu- 
lar Tissue  and  Tendons. — Contractures  and  Ankylosis. — Synonyms. — Etiology. 
— Pathology. — Diagnosis. — Prognosis. — Treatment. 


Index, 921-942 


ORTHOPEDIC   SURGERY. 


PART    I. 

GENERAL  ORTHOPEDIC  SURGERY. 


CHAPTER    I. 
INTRODUCTION   AND   HISTORY. 

The  word  "orthopedy"  (from  cpOuq,  "straight,"  and  -a?c,  "child") — 
Fr.,  orthopedie;  Ger.,  orthopddie;  It.,  ortopedia;  Span.,  ortopedia — according  to 
its  derivation  and  its  earher  use  implies  the  art  of  removing  deformities  in 
young  children.  In  the  present  day  its  meaning  has  been  extended  to  apply 
to  the  treatment  of  deformities  in  persons  of  all  ages.  From  its  derivation, 
again,  it  might  be  taken  to  embrace  the  rectification  of  a  great  variety  of 
abnormal  conditions  in  which  deformity  is  a  conspicuous  feature — the  reduc- 
tion of  dislocations,  the  removal  of  tumors,  etc. ;  but  in  modern  practice  the 
application  of  the  term  is  limited  to  certain  kinds  of  deformities,  especially 
those  of  a  chronic  and  progressive  character. 

Orthopedic  surgery  may  be  defined  as  that  department  of  surgical  science 
which  includes  the  preventive,  mechanical,  and  operative  treatment  of  chronic 
and  progressive  deformities. 

As  a  special  branch  of  medicine  its  influence  extends  in  three  directions. 
By  its  employment  of  gymnastics  it  enters  the  field  of  hygiene;  by  its  operative 
procedures  it  supplements,  but  does  not  invade,  the  realm  of  general  surgery; 
and  by  its  therapeutic  prevention  and  cure  of  deformities  it  advances  in  the 
path  of  practical  medicine. 

The  orthopedic  surgeon  of  today  must  be  an  educated  surgeon  in  every 
sense  of  the  word.  Carefully  trained  in  clinical  and  operative  surgery,  thor- 
oughly skilled  in  mechanical  principles,  he  must  be  equally  prepared  in  all 
three  branches  of  his  special  art:  the  treatment  and  prevention  of  orthopedic 
diseases,  the  application  of  apparatus,  and  the  performance  of  operations — 
in  other  words,  must  be  a  physician,  a  mechanician,  and  a  surgeon.     In  this 


2  ORTHOPEDIC  SURGERY. 

respect  the  orthopedist  most  resembles  the  ophthahnologist,  who  must  treat 
disease,  refract,  and  operate.  As  in  ophthalmic  practice  refraction  forms  the 
greater  part  of  the  work,  so  also  in  orthopedic  surgery,  measurement  and  the 
application  of  mechanical  appliances  will  demand  the  greatest  attention. 

In  the  medical  schools  and  universities  of  this  country  every  student  before 
graduating  is  instructed  in  the  fundamental  principles  and  practice  of  the 
orthopedic  art.  Particularly  is  he  instructed  in  the  use  and  application  of 
such  appliances  as  he  can  manufacture  for  himself. 

The  increasing  interest  in  this  subject  is  well  indicated  in  the  establish- 
ment of  special  dispensaries,  practical  courses,  and  clinical  professorships  in 
all  the  colleges  and  post-graduate  schools  in  this  country.  In  many  of  these, 
moreover,  as  the  University  of  Pennsylvania,  the  New  York  Orthopedic  Hos- 
pital, and  the  Boston  Children's  Hospital,  special  machine  shops  are  attached, 
in  which,  under  the  direct  supervision  of  the  surgeon,  the  mechanical  appli- 
ances are  made.  The  orthopedic  art  is  thus  elevated  in  importance  as  a  special 
branch  of  surgery,  and  the  orthopedic  surgeon  is  advanced  in  dignity  and 
reputation. 

History. 

The  study  of  the  history  of  orthopedy  is  best  divided  into  three  periods: 
the  precontinental  period;  the  continental  and  early  English  period,  the 
seventeenth  and  eighteenth  centuries ;  and  a  later  period  embracing  the  nine- 
teenth century  and  including  special  reference  to  American  contributions  and 
progress. 

Precontinental  Period. — The  history  of  orthopedics  is  coeval  with  medi- 
cine itself,  but  we  find  in  the  oldest  sources  of  medical  investigation  only  sparse 
references  to  this  subject.  Among  the  Chinese,  Egyptians,  and  Hindus  the 
surgery  of  deformities  is  only  a  reflection  of  ancient  tradition.  The  earliest 
writings  upon  the  causes  of  congenital  deformity  and  massage  of  the  body 
are  found  in  the  Ajur-Veda  of  Susruta,  about  800  B.  C.  In  the  writings  of 
Hippocrates,  500  B.  C,  collected  by  Polybius,  there  are  many  references  to 
this  subject,  especially  to  spinal  deformities  and  congenital  dislocation  of  the 
hip-joint  and  ankle-joint.  He  displayed  an  intimate  knowledge  of  club-foot 
in  his  treatise  "On  Articulations,"  and  described  a  method  of  correcting  in- 
fantile deformity  which  is  still  employed.  This  celebrated  Greek  physician 
opposed  the  violent  extension  and  counter-extension  with  pressure  as  practised 
upon  hunchbacks,  and  he  finally  describes  the  spinal  inflammation  accompanied 


Fig.  3. 
Forcible  Corkection  in  Time  of  the  Ancients. 


INTRODUCTION  AND  HISTORY.  5 

by  pain — the  "angina  of  Hippocrates."  He  employed  gymnastics  for  the 
development  of  the  muscular  system  and  employed  machines  alone  in  the 
treatment  of  deformities. 

'-^elsus,  13  to  55  A.  D.,  also  employed  actiye  and  passive  gymnastics  for 
the  relief  of  deformities,  with  massage  before  and  after.  He  does  not  even 
mention  club-foot,  foreshadowing  the  darkness  and  ignorance  of  the  Middle 
Ages. 

Soranus,  no  A.  D.,  refers  to  the  prevalence  of  crooked  legs  in  Rome,  and 
censures  the  women  of  his  time  for  allowing  children  to  walk  too  early. 

Galen,  130  to  206  A.  D.,  describes  spine  disease,  mentions  the  treatment 
of  scoliosis,  and  differentiates  this  disease  from  lordosis  and  kyphosis,  and 
refers  in  several  places  to  knock-knee. 

Caslius  Aurelianus,  210  A.  D.,  employed  gymnastics  and  splints  for  paral- 
ysis, and  Antillus,  about  400  A.  D.,  performed  tenotomy  for  contractures  and 
ankylosis. 

From  the  early  Arabian  physicians  a  few  imperfect  compilations,  more 
or  less  interpolated,  with  almost  no  original  work,  are  all  that  has  been  left 
to  medical  science.  The  earliest  deformity  discussed  by  them  was  excessive 
callus,  and  Rhazes,  852  A.  D.,  in  his  "Continent,"  and  Avicenna,  980  A.  D., 
in  the  "Canon,"  repudiated  the  use  of  all  rough  and  violent  methods. 

As  medicine  as  a  science  advanced,  the  radical  cure  of  hare-lip  described 
by  Galen,  Celsus,  and  the  Arabian  physicians,  became  a  common  operation. 
The  plastic  art  was  well  understood,  and  section  of  the  sternocleidomastoid 
muscles  for  the  relief  of  wry-neck  was  frequently  performed. 

During  the  Middle  Ages  cripples  were  considered  as  objects  of  Divine 
wrath,  were  regarded  as  subjects  of  ill  omen,  and  were  treated  with  horror  and 
disgust.  Superstition  withheld  aid  from  these  unfortunates  and  forbade  even 
the  mention  of  their  existence.  Influenced  by  this  belief  in  the  displeasure 
of  the  divinities,  and  also  desiring  to  avoid  the  baneful  influence  of  the  deformed 
upon  the  enceinte,  the  practice  became  prevalent,  under  the  barbarous  laws 
of  Lycurgus,  of  allowing  cripples  to  perish  from  want  and  neglect,  or  of  destroy- 
ing them  by  casting  them  into  the  Eurotas,  as  was  done  in  Sparta. 

This  effort  to  preserve  the  fitness  of  races  is  mentioned  by  Cicero  as  exist- 
ing among  the  Romans,  and  it  may  occasionally  be  observed  among  aboriginal 
tribes  even  at  the  present  time. 

Continental  and  Early  English  Period. — The  oppressive  gloom  of  the 
Dark  Ages  yielded  slowly  to  the  dawn  of  intellectual  light,  and  the  opposition 


6  ORTHOPEDIC  SURGERY. 

of  Islam  to  Christendom  was  ended.  Feudalism  was  replaced  by  the  forma- 
tion of  distinctive  nationalities,  and  medicine  as  a  science  once  more  began  its 
forward  march. 

The  only  contribution  of  any  importance  for  over  a  century  was  that  upon 
the  diseases  of  the  hip  and  spine  by  Albucasus,  iioo  A.  D.  The  real  foundation 
of  orthopedic  surgery  was  laid  by  Ambroise  Pare,  1561,  who  invented  a  steel 
corset  consisting  of  a  caraplace  and  plastron  in  which  the  spine  of  a  crooked 
person  was  laced,  and  who  described  the  treatment  of  club-foot  and  rickets. 
Severinus  Arcaeus,  a  Spanish  contemporary  of  Pare,  invented  some  apparatus; 
Fabricius  Hildanus,  1641,  devised  a  splint  for  straightening  the  elbow  and 
knee,  and  for  many  years  mechanical  appliances  were  the  only  means  employed 
in  the  treatment  of  deformities. 

The  year  1641  marks  an  important  advance  in  the  history  of  orthopedics, 
when  Isaac  Minnius  performed  an  open  section  of  the  sternomastoid  for  tor- 
ticollis, and  in  1660  Glisson  introduced  suspension  of  the  body  for  the  correc- 
tion of  spinal  affections,  and  published  his  celebrated  work  upon  rickets. 

As  a  special  branch  of  surgery  orthopedics  dates  its  existence  from  the 
time  of  Andry,  1741,  called  by  some  the  "father  of  orthopedic  surgery,"  who 
coined  for  it  a  name  in  his  book  upon  "The  Art  by  which  Bodily  Deformities 
of  Children  are  Prevented  and  Improved."  In  1778  Andre  Venel  settled  in 
Orb,  Switzerland,  and  founded  an  orthopedic  institution.  During  the  latter 
part  of  the  eighteenth  century  important  advances  were  made  by  Ludwig, 
1772,  and  Bottcher,  1792,  in  Germany;  Petit,  1758,  Levacher,  1768,  and  Por- 
tal, 1779,  in  France;  and  Pott,  1779,  and  Darwin,  1795,  in  England. 

The  practice  of  orthopedic  surgery  was  actively  pursued  at  this  time  by 
Naumberg,  1796,  and  Brucken,  1798,  in  Germany;  Typhaine  and  Verdier, 
1784,  in  France;  and  Sheldrake  and  Jackson,  1794,  in  England;  and  the  way 
was  prepared  for  the  brilliant  discovery  of  subcutaneous  tenotomy  and  its  estab- 
lishment as  a  principle  in  operative  medicine. 

The  Nineteenth  Century. — The  activity  manifested  at  the  close  of  the 
eighteenth  century  increased,  and  with  the  advent  of  the  nineteenth  century 
began  the  renaissance  of  orthopedics,  the  real  scientific  study  of  deformities. 
The  empirical  use  of  mechanical  appliances  which  formed  the  fundamental 
basis  of  the  treatment  of  deformities  by  the  earlier  surgeons  was  succeeded  by 
the  study  of  the  anatomy  and  pathology  of  these  affections  and  their  rational 
treatment.  In  1802  Scarpa  invented  a  club-foot  shoe  which  has  since  been 
used  as  a  model,  and  gave  a  complete  description  of  this  affection  wliich  has 


Fig.  7. — Steel  Corset 
Brace  with  Jury 
Mast  (De  la  Croix 
Skol,  1725). 


-Spine  Brace  with  Jury  Mast 
(Levascher,  1764). 


Fig.  II. — Suspension 
Apparatus  for 
Lateral  Curva- 
ture OR  Pott's 
Disease  (Vense, 
1788). 


Spine  Brace  (Portal, 
1767). 


Fig.  10. — Corrective  Appara- 
tus FOR  Spinal  Curvature 
(Levascher,  1768). 


Fig.  12.— Spine  Brace  (Schmidt,  1794).     Fig.  13.— Collar  and  Chin    Fig.  14.— Suspension  Apparatus    Fig.  15.— Suspension 

Piece  (Kohler,  1795).  (Glisson,  1799).  and     Corrective 

Apparatus     (Dar- 
win, 1801). 

Early  orthopedic  apparatus. 


TNTRODUCTION  AND  HISTORY.  9 

been  but  little  modified  since  his  time.  In  1806  there  appeared  a  work  upon 
deformities  by  Jorg.  The  greatest  mechanical  genius  of  this  time  in  Germany 
was  Johann  Georg  Heine,  who  established  the  first  German  orthopedic 
institution,  upon  the  plans  of  which,  succeeding  institutions  of  this  description 
have  since  been  based.  He  perfected  the  club-foot  shoe,  modified  the  exten- 
sion bed  of  Venel,  and  invented  several  orthopedic  appliances. 

The  first  work  in  which  stress  was  laid  upon  the  importance  of  mechanics 
in  anatomy,  physiology,  and  treatment  was  written  by  Heidenreich  in  1824, 
and  at  the  same  time  Wenzel  contributed  his  work  upon  diseases  of  the  spine, 
and  in  1837  Scoutettin  published  a  valuable  work  upon  club-foot.  The  most 
important  advance  of  this  period  in  Germany  was  the  perfection  of  the  method 
of  subcutaneous  tenotomy  of  the  tendo  Achillis,  by  Stromeyer,  1831. 

During  this  time  the  influence  of  the  teaching  of  Peter  Henry  Ling,  1816, 
in  regard  to  the  use  of  gymnastics  in  orthopedics  was  making  itself  felt  in  Ger- 
many and  France,  and  for  many  years  the  discussion  continued  as  to  the  rela- 
tive merits  of  the  dynamic  and  the  gymnastic  forms  of  treatment.  On  the 
one  side  were  arrayed  Schilling,  Werner,  Wildberger,  and  Biihring  for  mechan- 
ical treatment,  and  upon  the  other  side  Ulrich,  Nitzsche,  and  Melliche  for  gym- 
nastic treatment. 

In  France  subcutaneous  tenotomy  of  the  sternomastoid  muscle  was  prac- 
tised by  Dupuytren,  1821,  Bouvier,  1836,  and  J.  Guerin,  1837.  The  treat- 
ment of  deformities  was  generally  carried  out  in  institutions,  and  in  1830  there 
existed  no  less  than  ten  of  these  orthopedic  establishments  in  Paris.  The  dis- 
cussion as  to  the  dynamic  and  gymnastic  principles  in  orthopedics  was  also 
carried  on  in  France,  the  emphasis  which  had  been  laid  upon  the  value  of 
gymnastic  treatment  by  Andry  and  Portal  being  upheld  by  Lachaise,  who  con- 
demned the  exclusive  use  of  extension  beds  and  objected  to  their  being  used 
except  as  an  adjunct.  At  this  time  the  Academy  of  Sciences  in  Paris  ofl'ered 
a  prize  for  the  best  paper  upon  the  question  of  the  treatment  of  deformities 
by  means  of  gymnastics  or  by  the  application  of  mechanical  appliances.  Tliree 
contests  were  held  without  any  decision  being  made,  and  it  was  not  until  eight 
years  later  that  the  prize  was  awarded  to  Bouvier  and  J.  Guerin.  To  Delpech, 
in  1828,  the  scientific  founder  of  orthopedics,  this  branch  of  surgery  is  indebted 
for  his  success  in  harmonizing  the  two  methods,  and  preserving  the  best  in 
each.  To  him  also  belongs  the  credit  of  having  first  performed  subcutaneous 
section  of  the  tendo  Achillis.  This  first  operation,  however,  was  ineft'ectual 
on  account  of  the  suppuration  of  the  wound,  but  the  modification  of  the  sub- 


10  ORTHOPEDIC  SURGERY. 

cutaneous  method  by  Stromeyer  robbed  the  proceeding  of  its  dangers  and 
rendered  it  successful.  Prior  to  this  time  tenotomies  were  performed  by  the 
open  method.  Delpech  showed  the  advantages  of  the  subcutaneous  method, 
and  his  suggestions  were  followed  by  all  the  prominent  orthopedic  surgeons 
of  the  time,  especially  by  Duval,  Pravaz,  Jules  Guerin,  and  Bonnet,  and  Piro- 
goff  in  Russia  contributed  a  valuable  monograph  upon  the  histology  of  tenotomy. 
Like  many  other  great  discoveries  in  surgery,  subcutaneous  tenotomy  was  at 
first  recklessly  and  extravagantly  performed,  so  that  until  about  sixty  years 
ago  orthopedic  surgery  was  a  despised  and  rejected  art. 

In  England  the  progress  of  orthopedic  surgery  WcCs  slow,  and  in  1801  Ben- 
jamin Bell  criticized  the  lack  of  knowledge  of  orthopedics  possessed  by  the 
physicians  of  his  day,  and  declaimed'  against  traveling  mechanicians.  Perhaps 
the  most  important  work  of  the  period  was  that  by  Harrison,  1820,  upon  Scoliosis. 
The  necessity  for  scientific  work  in  this  branch  was  felt  by  the  profession,  and 
in  order  to  encourage  investigation  the  Medical  Society  of  London  offered  the 
Hunterian  prize,  1822,  for  the  best  original  work  upon  the  value  of  mechan- 
ical means  in  the  cure  of  deformities  of  the  vertebral  column.  The  important 
work  of  Sir  Benjamin  Brodie  in  1834  upon  diseases  of  the  joints  was  an  epoch- 
making  book,  and  became  the  standard  for  all  subsequent  works  upon  this 
subject. 

The  important  discovery  of  subcutaneous  tenotomy  was  brought  into 
England  by  Little,  a  patient  and  pupU  of  Stromeyer,  and  kno^^m  as  the  "apostle 
of  tenotomy,"  who  established  a  Royal  Orthopedic  Hospital  in  London  in 
1837,  and  in  1853  published  a  work  upon  deformities  which  continued  popular 
until  the  close  of  the  century,  and  which  may  stUl  be  consulted  "v\ath  profit. 
Among  the  most  important  studies  in  England  during  the  first  half  of  the  cen- 
tury were  the  valuable  works  upon  curvatures  of  the  spine  by  Shaw,  Bamfield, 
Tamplin,  and  Bishop.  All  of  these  may  be  consulted  mth  profit  at  the  present 
time  by  any  one  interested  in  the  mechanical  causes  of  distortions. 

Between  the  years  1850  and  1870  the  progress  of  orthopedics  was  slow, 
notwithstanding  the  important  discovery  of  anesthesia.  In  Germany  there 
appeared  the  distinguished  work  of  the  Weber  brothers,  1856,  upon  the  "Statics 
and  Mechanics  of  the  Human  Body."  This  furnished  a  stimulus  for  the  sub- 
sequent work  of  Ludwig,  Henke,  von  Meyer,  and  Langer.  During  this  period 
Langenbeck  introduced  subcutaneous  osteotomy,  in  1854. 

In  France  there  appeared  the  works  of  Malgaigne,  1862,  and  of  C.  Gaujot 
and  E.  Spillman,  1867. 


INTRODUCTION  AND  HISTORY.  11 

In  England  Barwell  introduced  the  use  of  rubber  muscles,  and  there  ap- 
peared contributions  to  orthopedic  literature  from  L.  J.  Chance,  who  invented 
a  spine  brace;  Heather  Bigg,  upon  the  subject  of  deformities  of  the  spine; 
W.  Adams,  upon  club-foot,  and  by  Brodhurst  upon  ankylosis. 

From  1870  to  the  end  of  the  century  orthopedic  surgery  advanced  with 
rapid  strides,  partly  on  account  of  the  discovery  of  the  tubercle  bacillus  by  Koch 
in  1882  and  particularly  on  account  of  Lister's  great  discovery  of  antiseptic 
surgery,  which  made  the  performance  of  all  operations  a  much  less  dan- 
gerous proceeding  than  before,  and  assured  a  cure  in  a  great  number  of 
cases.  Surgery  began  to  be  practised  in  connection  with  orthopedics  much 
more  generally,  and  was  attended  by  many  successful  results,  when  em- 
ployed in  connection  with  mechanical  apJDliances  as  an  after-treatment.  The 
operation  of  arthrodesis  was  first  performed  during  this  period  by  Albert, 
of  Vienna,  and  also  by  Wolff  in  Germany.  Open  section  of  the  tendons  was 
also  revived  at  this  time  by  Treves,  Volkmann,  and  Lorenz,  and  Hoffa  in- 
troduced the  open  operation  for  reducing  congenital  dislocations  of  the  hip. 
Beely  advanced  the  subject  of  the  treatment  of  spinal  deformities,  and  in- 
vented several  appliances  and  machines. 

In  France  the  operation  of  osteoclasis  was  practised  by  Delore,  the 
credit  for  perfecting  a  new  method  of  osteoclasis  which  has  since  been  of 
great  service  to  the  orthopedic  surgeon  being  due  to  Robin,  who  with  Collin 
manufactured  an  osteoclast  which  enabled  the  operation  to  be  performed 
with  great  success. 

In  Italy  Rizzoli  invented  an  osteoclast  and  advanced  the  subject  of 
osteoclasis  very  materially.  Palletta  contributed  some  valuable  work  in 
connection  with  the  subject  of  congenital  dislocation  of  the  hip,  and 
there  was  also  at  this  time  Panzeri  and  Magary,  who  established  the 
"Archivio  di  Ortopedia"  in  Milan,  1884,  and  who  advanced  the  practical 
treatment  of  deformities  very  greatly  in  their  country.  Von  Motta  and 
Cordivilla  also  contributed  some  valuable  works  upon  orthopedics  at  this 
period. 

In  England  Bernard  Roth  has  contributed  a  valuable  and  extensive 
work  on  lateral  curvature  of  the  spine,  and  there  have  appeared  contribu- 
tions by  Little,  upon  in-knee,  Parker,  on  club-foot,  and  Edmund  Owen, 
upon  surgical  diseases  of  children.  Hugh  Owen  Thomas  invented  a  num- 
ber of  splints,  and  Robert  Jones  succeeded  him  and  carried  on  this  work, 
also  contributing  several  very  valuable  papers  upon  orthopedics. 


12  ORTHOPEDIC  SURGERY. 

During  this  period  many  orthopedic  hospitals  and  institutions  were 
established  in  London,  notably  the  Royal  Orthopedic   Hospital. 

This  last  quarter  of  the  nineteenth  century  witnessed  the  production  of 
many  valuable  contributions  to  the  literature  of  orthopedics.  In  England 
there  was  a  very  important  monograph  upon  "Spinal  Caries"  by  Heather 
Bigg,  and  among  th'e  most  valuable  of  the  larger  treatises  were  those  of 
Reeves,  Tubby,  Keetley,  and  Clarke.  In  Germany  we  have  those  of 
Schreiber,  Hoffa,  and  Joachimsthal,  and  in  France  those  of  de  Saint-Germain, 
Kirmisson,  Lannelongue,  Redard,  and  Berger  and  Banzet. 

There  were  also  established  in  France  at  this  time  two  principal  ortho- 
pedic publications,  the  "Annales  de  Chirurgie  et  Orthopedic,"  by  Bilhaut, 
and  the  "Revue  Orthopedie,"  by  Kirmisson. 

American    History. 

In  this  country  orthopedic  surgery  has  always  claimed  the  attention  of 
the  profession  and  its  advances  have  kept  pace  with  the  progress  in  Europe. 
From  the  time  of  the  establishment  of  medical  institutions  of  learning,  in 
1763,  and  for  half  a  century  afterward,  medical  thought  and  practice  were 
influenced  by  the  schools  of  Edinburgh,  London,  and  Leyden.  After  1820 
British  influence  began  to  wane,  the  influence  of  French  teaching  began  to 
be  experienced,  and  for  thirty  years,  1830  to  i860,  medical  literature  and 
practice  were  entirely  dominated  by  the  Gallic  school.  The  influence  of 
German  medicine,  which  had  been  steadily  growing  for  a  score  of  years, 
1840  to  i860,  produced  a  decided  change  of  allegiance,  which  continued  to 
the  close  of  the  nineteenth  century. 

At  certain  periods  in  the  history  of  this  subject  trans-Atlantic  methods 
have  been  remodeled  upon  cis-Atlantic  principles,  notably  the  introduction 
of  the  long  fracture  splint  of  Physick,  and  the  employment  of  traction  in  the 
so-called  "American  method"  of  treating  joint  disease  and  deformity  (by 
which  title  it  is  known  throughout  Europe  at  the  present  time),  by  Davis  and 
Taylor,  and  also  the  introduction  into  Europe  of  plaster-of-Paris  jackets  by 
Sayre. 

During  the  first  period  the  great  Physick  taught  English  methods,  and 
Dorsey's  "Elements,"  1813,  were  largely  Hunterian  teaching  as  reflected  by 
his  pupil.  The  third  edition  of  this  work,  edited  by  Randolph,  was  used  as 
a  text- book  in  the  University  of  Edinburgh,  the  foremost  school  in  the  world. 

During  the  second  period  Barton,    1826,  performed  the  first  osteotomy 


INTRODUCTION  AND  HISTORY.  13 

of  the  hip,  in  1824  Gibson's  comprehensive  work  on  surgery  appeared,  and 
Gross,  in  his  "Bones  and  Joints,"  1830,  recommended  the  use  of  adhesive 
plaster  for  extension  and  counter-extension.  The  great  discovery  of  Stro- 
meyer  was  brought  into  this  country  by  Rogers,  1834,  Dickson,  1835,  and 
Detwold,  1837;  and  in  1844  Mutter  published  a  monograph  upon  club-foot. 
In  1850  Carnochan  published  his  complete  treatise  upon  "Congenital  Dis- 
location of  the  Head  of  the  Femur,"  and  in  1852  the  first  excision  of  the  hip 
in  this  country  was  performed  by  Bigelow.  The  greatest  genius  of  this 
period  was  Henry  G.  Davis,  who,  in  1857,  invented  the  continued  elastic  ex- 
tension, the  so-called  "American  method  of  treating  joint  disease  and  de- 
formities," and  who  also  introduced  the  use  of  rubber  muscles. 

The  third  period  was  marked  by  advances  in  the  treatment  of  diseases 
of  the  joints  by  Hodges,  Nott,  Markoe,  and  others,  and  the  treatment  of 
affections  of  the  spine  by  Ashhurst,  Lee,  and  others.  Bauer,  1861,  devised 
a  wire  breeches  for  the  treatment  of  hip-joint  disease.  Prince,  in  1866,  pub- 
lished his  "Plastics  and  Orthopedics,"  and  C.  F.  Taylor  invented  a  spine 
brace  and  hip  splint  which  are  universally  employed.  The  most  enthusiastic 
exponent  of  the  orthopedic  art  during  this  period  was  Lewis  A.  Sayre,  who 
invented  the  plaster-of-Paris  jacket  and  extended  its  use  throughout  the  civi- 
lized world.  In  1861  the  great  exponent  of  conservative  orthopedics,  Buck- 
minster  Brown,  estabHshed  the  Samaritan  Hospital,  in  Boston,  and  in  1863 
Knight  established  the  Hospital  for  Ruptured  and  Crippled,  in  New  York. 
The  New  York  Orthopedic  Hospital  was  established  by  Shaffer  in  1871,  and 
the  New  York  State  Hospital  for  Crippled  and  Deformed  in  1900. 

The  year  1887  marks  an  important  year  in  the  history  of  orthopedic 
surgery  by  the  organization  of  the  American  Orthopedic  Association,  among 
the  charter  members  of  which  appear  such  distinguished  names  as:  E.  H. 
Bradford,  Buckminster  Brown,  C.  C.  Foster,  V.  P.  Gibney,  A.  B.  Judson, 
Benjamin  Lee,  R.  W.  Lovett,  Thos.  G.  Morton,  Roswell  Park,  John  Rid- 
lon,  A.  Sydney  Roberts,  Lewis  H.  Sayre,  Reginald  H.  Sayre,  Newton  M. 
Shaffer,  A.  J.  Steele,  Henry  L.  Taylor,  Ap  Morgan  Vance,  and  DeForest 
Willard. 

The  contributions  of  this  Association  to  the  literature  of  orthopedics 
have  been  many  and  valuable,  but  the  recent  history  of  this  branch  of  sur- 
gery is  so  accessible  and  so  voluminous  that  a  detailed  account  of  recent  con- 
tributions is  not  within  the  scope  of  this  work  except  as  it  occurs  under  the 
head  of  the  various  subjects  treated  in  Part  II.     For  a  complete  bibliography 


14  ORTHOPEDIC  SURGERY. 

of  the  works  of  the  members  of  the  American  Orthopedic  Association  the 
reader  is  referred  to  volume  xv  of  the  Transactions  of  the  Association. 

Among  some  of  the  most  important  treatises,  however,  we  may  here 
note  those  of  Knight,  Sa3Te,  Bradford  and  Lovett,  Young,  Whitman,  Mc- 
Curdy,  and  Judson.  Important  monographs  on  diseases  of  the  hip  have 
been  contributed  by  Gibney,  Lovett,  and  AUis,  and  on  joint  diseases  by  Rid- 
lon  and  Jones. 

The  estabhshment  of  the  "American  Journal  of  Orthopedic  Surgery," 
under  the  auspices  of  the  American  Orthopedic  Association,  marks  one  of 
the  most  important  advances  in  the  recent  literature  of  this  most  important 
branch  of  surgery. 


CHAPTER  II. 

GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 

In  considering  the  subject  of  etiology  it  is  best  to  make  two  divisions, 
congenital  and  acquired. 

Congenital  Deformity. 

The  study  of  the  causes  of  congenital  deformity  reveals  much  that  is 
obscure  and  unexplained.  These  deformities  may  be  considered  under 
two  groups — those  which  are  due  to  primary  change  occurring  in  the 
ovum,  or  during  the  development  of  the  fetus,  and  those  which  occur  to 
the  fetus  after  it  has  been  properly  formed.  The  former  are  malforma- 
tions, and  as  teratogenic  conditions  are  of  more  especial  interest  to  the 
teratologist  and  obstetrician,  only  a  few  subjects  surviving  with  spina 
bifida,  hare-lip,  etc.  The  latter  are  true  deformities  and  may  occur  from 
influences  acting  upon  the  healthy  fetus  or  influences  upon  a  fetus  which  is 
diseased.  The  different  theories  which  have  been  advanced  to  account  for 
deformity  include  the  theory  of  heredity,  the  theory  of  intrauterine  pressure 
or  traumatism,  the  theory  of  pre-natal  disease,  and  the  theory  of  arrest  or 
defect  of  development. 

Heredity. — The  effect  of  heredity  upon  the  production  of  certain  de- 
formities has  long  been  recognized.  Thus,  we  have  club-foot,  congenital 
dislocations,  certain  nervous  affections,  as  progressive  musc?ular  atrophy,  and 
occasionally  lateral  curvature.  The  hereditary  affection  may  occur  through 
one  or  both  of  the  parents,  and  this  is  particularly  true  of  consanguineous 
marriages. 

Intrauterine  Pressure  or  Traumatism. — That  deformities  may  result 
from  intrauterine  pressure  or  traumatism  has  long  been  recognized  by  both 
the  profession  and  the  laity.  The  exact  manner  in  which  the  deformity  is 
produced  has  been  disputed  and  still  remains  unsettled.  That  it  may  be 
the  result  of  a  fall,  a  blow,  or  undue  compression  is  proved  by  the  experi- 
mental studies  which  have  of  late  been  undertaken,  and  by  the  deformities 
which  appear  to  have  followed  directly  upon  direct  violence.  Dareste,  Fan- 
nin,  Warynski,   Foe,   and   Lombardine  have  made   some  interesting  experi- 

15 


16 


ORTHOPEDIC  SURGERY. 


ments  with  chickens'  eggs,  varnishing  them  during  the  incubation  time,  rais- 
ing and  lowering  the  temperature,  injecting  substances  into  them,  etc.,  thus 
producing  various  monstrosities  and"  absences  of  parts  in  the  chickens.  While 
the  deformity  may  be  produced  by  direct  compression,  it  is  more  frequently 
the  result  of  the  interference  occurring  from  the  compression  upon  the  nor- 
mal development  of  the  part.  Thus,  in  club-foot  the  compression  interferes 
with  the  normal  rotation  outward  of  the  tibia,  and  in  this  manner  prevents 
proper  development. 

In  this  connection  the  effect  of  maternal  impressions  as  a  factor  in  pro- 
ducing deformities  should  be  considered.  In  exceptional  instances  the  de- 
formities resemble  some  object  which  through  shock  or  fright  has  made  an 
impression  upon  the  mother,  but  can  usually  be  accounted  for  in  some  other 

way,  or  the  fright  has  occurred 
at  a  period  of  the  pregnancy 
when  the  effect  on  the  fetus 
could  not  have  been  so  pro- 
nounced. 

The  effect  of  maternal  im- 
pression in  the  production  of 
club-foot,  the  one  most  fre- 
quently attributed  to  this  cause, 
has  been  found  not  to  have  been 
a  real  factor  in  a  single  instance, 
and  in  general  the  effect  of  ma- 
ternal impressions  is  so  slight 
that  it  may  be  disregarded. 
Pre-natal  Disease.— The  effect  of  pre-natal  disease  in  producing  de- 
formity cannot  be  denied,  since  lesions  similar  to  those  occurring  in  the  pre- 
natal period,  especially  rickets  and  lesions  of  the  central  nervous  system,  are 
not  infrequently  found  to  exist  in  the  post-natal  period.  The  association 
of  extensive  nervous  lesions,  such  as  spina  bifida,  anencephalus,  or  hydro- 
cephalus, has  seemed  to  confirm  this  theory,  but  club-foot  is  not  always 
present. 

Arrest  or  Defect  of  Development. — The  theory  of  arrest  of  develop- 
ment, or  the  osseous  theory,  is  a  very  popular  one  at  the  present  time, 
confirmed  as  it  is  by  such  deformities  as  spina  bifida,  cleft  palate,  and  hypo- 
spadias.    This  theory  has  been  rendered  more  popular  by  the  so-called  archio- 


FiG.  i6. — Intrauterine  Rickets  (Ballantyne). 


Fig.  17. — Aekest  of  Growth  fkom  Deposit  of  Bone. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  19 

terigium  or  ray  theory.  This  theory,  which  describes  the  histologic  develop- 
ment upon  the  rays  from  a  common  center  diverging  in  different  directions, 
seems  to  be  supported  in  instances  of  some  deformities  by  reason  of  the  ab- 
sence of  all  the  parts  included  within  certain  radii.  In  the  most  important 
deformities  ascribed  to  this  cause  there  is  the  congenital  absence  of  bony 
parts.  Another,  the  amniotic  theory,  also  sufficiently  explains  the  produc- 
tion of  most  of  these  deformities,  so  that  the  theory  of  arrest  of  development 
is  not  so  important  as  at  first  appeared. 

The  occurrence  of  deformity  resulting  from  primary  changes  in  the 
bones,  such  as  in  the  astragalus  or  the  os  calcis  in  club-foot,  cannot  be  de- 
nied, but  there  is  still  much  difference  of  opinion  in  regard  to  the  deformi- 
ties of  these  parts  as  to  whether  they  are  causative  or  the  result  of  pressure. 
The  arrest  of  growth  where  the  parts  are  perfectly  formed  is  most  difficult 
to  explain.  It  might  be  due  to  partial  cutting-off  of  blood-supply^schemia. 
In  some  instances  it  is  due  to  disease  and  too  early  deposit  of  bone  in  the 
epiphyses,  arresting  the  growth. 

The  subject  of  congenital  deformities  will  be  considered  more  fully  in 
taking  up  each  individual  affection  under  its  own  heading. 

Acquired  DEFORinxiES. 

By  far  the  larger  number  of  deformities  are  acquired  as  the  result  of 
traumatism,  faulty  attitudes  (static  or  habitual),  constitutional  causes,  and 
deformities  secondary  to  inflammatory  disease. 

Traumatic  Deformities. — The  deformities  due  to  traumatism  usually 
occur  from  fractures  or  dislocations  of  the  bones.  Deformity  from  a  fracture 
may  be  produced  by  a  faulty  union  of  the  part,  changing  the  relations  of  the 
adjacent  structures,  or  it  may  be  due  to  an  interference  with  the  growth  of 
the  part.  This  is  particularly  true  where  the  injury  involves  the  epiphysis. 
In  some  cases  the  bone  increases  in  length  from  irritation  of  the  epiphysis, 
and  in  others  it  remains  undeveloped  from  destruction  of  the  epiphysis,  the 
deformity  resulting  from  the  adjoining  bones.  Thus,  we  have  deformity  in 
the  hand  resulting  from  injury  to  the  radius,  or  deformity  of  the  foot  from 
injury  to  the  fibula. 

When  luxations  occur,  the  deformity  is  produced  by  the  changed  posi- 
tion of  the  parts,  and  also  from  the  changes  which  occur  in  the  structure  of 
the  articular  surfaces  from  the  alteration  in  the  function. 

Static  or  Habitual  Deformities. — There  has  been  some  difference  of 


20  ORTHOPEDIC  SURGERY. 

opinion  as  to  the  origin  of  this  variety  of  deformities,  as  to  whether  it  is  due 
to  cause  or  to  effect. 

For  many  years  the  theory  known  as  the  \'olkmann-Huetter  theory  has 
been  the  one  generally  accepted.  This  theory  asserts  that  on  account  of 
muscular  weakness  a  faulty  attitude  is  assumed,  and  deformity  follows  by 
reason  of  the  greater  pressure  which  is  made  upon  one  side,  while  the  other 
side  is  subjected  to  a  pressure  less  than  normal,  as  in  genu  valgum  the  outer 
side  of  the  joint  bears  the  greater  weight,  while  the  inner  side  bears  a  sub- 
normal weight.  By  the  theory  that  under  normal  conditions  the  develop- 
ment depends  upon  the  intra-articular  pressure  the  deduction  is  made  that 
any  increased  pressure  on  the  concave  side  would  interfere  with  the  normal 
development  of  the  bone,  and  even  cause  atrophy  of  the  bone  already 
formed,  while  the  lessening  of  the  normal  pressure  upon  the  internal  side 
W'Ould  cause  an  excess  of  growth  on  that  side.  This  theory,  known  as 
the  "  pressure "  or  "  superincumbent  weight "  theory,  has  been  upheld 
by  Roser,  Lorenz,  Hoffa,  Schreiber,  Redard,  Judson,  Bradford,  and  Whit- 
man. 

In  contradistinction  to  this  theory  we  have  that  advanced  by  Julius 
Wolff,  1892,  and  known  as  "Wolff's  law."  After  a  careful  study  of  the 
correspondence  between  the  structure  of  bone  in  normal  and  abnormal  con- 
ditions, combined  with  certain  calculations  of  graphic  statics,  he  deduced  a 
theory  of  the  "functional  pathogenesis"  of  deformity.  This  he  calls  the 
"law  of  transformation,"  and  states  that  he  believes  it  to  have  its  strongest 
confirmation  in  the  striking  resemblance  to  be  found  between  the  internal 
architecture  of  the  normal  femur  and  the  grapho-static  diagram  of  a  Fair- 
bairn  crane,  as  drawTi  by  the  mathematician  Culmann.  The  outline  of  this 
crane,  bearing  a  load  of  30  kilograms,  which  is  approximately  the  aver- 
age weight  borne  by  the  normal  adult  femur,  shows  a  remarkable  analogy 
to  that  of  the  human  femur,  -without  the  trochanter  major.  Von  Meyer  has 
called  attention  to  this  analogy  between  the  courses  of  the  bone  trabeculae 
in  the  human  femur  and  the  trajectories  of  the  crane  in  Culmann's  draw- 
ing. While  developing  his  theory  Wolff  asserted  that  the  similarity  be- 
tween the  spongiosa  in  the  sagittal  section  of  the  femur  and  the  "neutral 
plane"  of  Culmann's  drawing  was  in  accordance  with  the  requirements  of 
the  grapho-static  figure,  which  assertion  he  confirmed  later  on  by  anatomic 
proof. 

Upon  the  completion  of  his  study  upon  the  subject  Wolff"  resolved  his 


B^ 


&:§ 


Qg 


<  5 

►J  3 

o  « 

I  < 


21? 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


23 


theory  into  the  following  proposition:    "Every  change  in  the  form  and  func- 
tion of  the  bones,  or  of  their  function  alone,  is  followed  by  certain  definite 
changes  in  their  internal  architecture,  and  equally  definite  secondary  alter- 
ations of  their  external  conformation,  in 
accordance  with  mathematical  laws." 


Fig.  21. — Deformity   Following    Fracture  of 
Femur  (Wister  Institute  of  Anatomy). 


Fig.  2  2. — Coxa  Vara  Following  Fractuke  of 
Neck  of  Femur  (Philadelphia  College  of 
Physicians). 


Up  to   the  present   time   this  "law"  has  not   been   generally  accepted, 
although  its  probability,  along  certain  lines,  has  been  recognized.     The  chief 


24 


ORTHOPEDIC  SURGERY. 


reason  for  its  non-acceptance  is  the  impossibility  of  substantiating  it  by" 
mathematical  proof.  This  would  be  an  exceedingly  difficult  task,  as  it  is 
almost  impossible  to  compute  with  mathematical  exactness  the  ph_vsical  char- 
acteristics of  the  bones,  and  the  complex  problem  of  the  construction  of  the 
femur  and  the  amount  of  muscular  stress  devolving  upon  it.  This  is  espe- 
cially true  since  the  great  trochanter  is  left  out  of  the  calculation  entirely, 
whereas  it  is  always  present  and  is  an  important  factor  in  the  amount  of 

muscular  stress  borne  by  the  femur. 
Wolff  himself  said :  "I  also  concede 
that  the  conditions  in  the  live  organ- 
ism are  much  more  complicated  than 
they  can  appear  in  the  mere  observa- 
tion of  Culmann's  drawing.  INIany 
anatomic  and  mathematical  re- 
searches will  be  necessary  to  com- 
plete our  knowledge  in  this  direc- 
tion." 

That  there  is  fundamental  truth 
in  Wolff's  law  is  proved  in  cases  of 
mal-union  of  the  fractured  humerus, 
where  superincumbent  weight  would 
not  be  a  factor,  or  in  a  case  of  severe 
congenital  talipes  equino- varus,  noted 
by  Wolff,  where  the  child  had  never 
walked.  He  states  in  mentioning 
this  case  that  the  bone  transforma- 
tion constitutes  the  deformity  and 
that  function  is  consequent  upon  this 
transformation.  In  cases  of  incipient 
scoliosis  where  the  bones  are  not  involved  this  law  would  not  apply,  and  the 
theory  of  superincumbent  weight  would  be  more  probable. 

That  function  alone  is  the  cause  of  deformity  is  largely  open  to  ques- 
tion. Wolff,  in  writing  upon  the  pathology,  asserts  that  both  the  internal 
architecture  and  the  configuration  are  changed,  as  well  as  the  external  con- 
formation; that  the  deformity  is  due  entirely  to  the  functional  changes  in 
the  bone;  and  that  "the  shape  of  the  bones  and  joints  of  the  deformed  parts 
represents   nothing   else   than    the    functional    accommodation    to   the   faulty 


Fig.  2v — C0NGENIT.A.L  Absence  of  Femur  (Jones). 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  25 

sialic  demands  made  upon  it."  This  statement  would  appear  to  include, 
under  the  head  of  "static  demands,"  what  has  been  generally  known  as 
faulty  or  unavoidable  attitudes  assumed  by  patients,  these  being  the  funda- 
mental cause  of  the  deformity,  which  is  augmented  by  the  functional  trans- 
formation of  the  bones. 


Fig.  24. — Congenital  Absence  of  Femur.     X-Ray  (Jones). 

From  a  therapeutic  standpoint  Wolff's  law  is  of  value  in  emphasizing 
the  importance  of  over-correction  in  genu  valgum  and  genu  varum  and  in 
scoliosis.  It  has  also  been  of  service  in  the  correction  of  conditions  such  as 
coxa  vara,  as  it  has  thrown  much  light  upon  the  static  demands  of  these 
conditions. 


26 


ORTHOPEDIC  SURGERY. 


In  this  variety  of  deformity,  wliether  produced  by  cause,  superincum- 
bent weight,  or  by  effect,  as  the 
result  of  functional  changes,  there 
are  certain  characteristic  altera- 
tions in  the  parts  upon  which 
the  weight  or  "burden-bearing" 
devolves.  These  alterations  are 
called  by  the  general  term  of 
atrophy  by  the  upholders  of  the 
theory  of  superincumbent  weight. 
Atrophy,  in  its  actual  sense,  how- 
ever, cannot  be  said  to  occur,  as 
may  be  seen  by  a  study  of  sec- 
tions of  diseased  bones,  but  there 
is  always  present  a  lessening,  or 
osteosclerosis,     on     the     concave 


Fig.  25. — Faulty  .Attitude  (.Artist's  Model).  Fig.  26. — Lateral  Curvature  frum  Absent 

Tibia  (Erich). 


side  of  the  deformity,  and  a  thickening,  or  osteoporosis,  on  the  conve.K  side. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


27 


In  regard  to  the  production  of  deformity  from    faulty  attitudes,  it  has 
now  become  an  estabHshed  fact  that  scohosis  is,  as  a  general  rule,  due  to  this 


Fig.  27. — Lateral  Curvature.     Bony  Specimen  (Philadelphia  College  of  Physicians). 


cause,  and  the  manner  in  which  it  is  produced  is  interesting.     As  the  result 
of  fatigue  an  attitude  of  rest,  with  the  weight   of   the    body  throAvn  entirely 


28 


ORTHOPEDIC  SURGERY. 


upon  one  side,  is  assumed  by  cliildren.  This  produces  an  elongation  and 
relaxation  of  the  extended  limb,  while  the  limb  upon  which  the  weight  rests 
remains  normal  or  slightly  over-developed.  When  the  child  assumes  the 
correct  position,  the  increased  length  in  the  extended  limb  causes  a  tilting 
of  the  pelvis,  with  curvature  of  the  lumbar  vertebras  toward  the  short  limb, 
and  later  a  compensatory  curve  in 
the  dorsal  region. 

The  occurrence  of  flat-foot  from 
faulty  positions  is  the  result  of  the 


Fig.  28. — Rachitic  Knock-knee. 


. — Rachitic  Knock-knee.     Bony  Specimen 
(Philadelphia  College  of  Physicians). 


breaking-down  of  the  plantar  ligaments  and  fascias  from  the  continued 
pressure  of  the  superincumbent  weight.  The  production  of  rachitic  de- 
formities about  the  knee-joint  due  to  superincumbent  weight  varies  with 
the  manner  in  which  the  weight  falls  upon  the  part.  If  the  limbs  are  widely 
separated,  the  resulting  deformity  will  be  a  bow-leg.     If  the  knees  are  close 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


29 


together  or  if  one  knee  only  is  inclined  inward,  the  resulting  deformity  will 
be  knock-knee,  single  or  bilateral.  The  deformity  at  the  knee-joint  in 
rickets   is   frequently   produced   by  the   pressure   of  the  arm  of   the    mother 


Fig.  30. — Scoliosis  Produced  by  Faulty  Manner  or  Carrying  Child. 

in  carrying  the  child,  the  deformity  in  unilateral  rachitic  genu  valgum 
being  always  on  the  side  pressed  by  the  arm  upon  which  the  child  is  sup- 
ported. 

Vestmentary  Deformities. — In  this  connection  the  deformities  produced 


30  ORTHOPEDIC  SURGERY. 

by  pressure  other  than  superincumbent  weight  should  be  considered.  These 
deformities  are  sometimes  spoken  of  as  "vestmentary  deformities,"  since  they 
are  produced  by  the  pressure  of  the  clothing,  shoes,  etc.  The  deformities 
produced  by  pressure  from  the  use  of  corsets  are  not  so  common  at  the  present 
time  as  formerly,  since  the  practice  of  wearing  corsets  has  been  abandoned  by 
many  persons,  and  the  faulty  construction  of  the  corset  has  been  largely  over- 
come. The  injurious  effects  of  corset  pressure  are  seen  in  the  unsightly  deposit 
of  adipose  about  the  hips  and  upper  thigh,  and  in  the  atrophy  of  the  subcuta- 
neous tissue  and  the  rectus  abdominis  and  longissimus  dorsi  muscles  about  the 
waist  line.  Too  much  credit  cannot  be  given  to  the  gifted  writer  of  "Gates 
Ajar,"  and  her  contemporaries,  for  the  influence  which  they  have  exerted  upon 
the  philosophy  of  clothing  and  the  manner  in  which  they  have  emancipated 
women  "from  corsets  that  embrace  the  waist  with  a  tighter  and  steadier  grip 
than  any  lover's  arm,  and  skirts  that  weight  the  hips  with  heavier  than 
maternal  burdens." 

There  is  still  a  field  partially  unoccupied  which  deals  with  the  defective 
dressing  of  children,  and  Noble  Smith,  Bradford,  and  others  have  added  the 
weight  of  their  influence  in  the  endeavor  to  remedy  this  evil. 

Deformities  produced  by  faulty  clothing  in  growing  children  are  evi- 
denced in  the  drooping  head,  rOund  shoulders,  hollow  back,  and  weak  walk 
of  the  present  generation.  If  one  compares  the  French  statue  of  today  with 
the  ideals  beheld  in  the  statues  of  the  past,  the  contrast  is  striking.  Instead 
of  the  full  neck,  high  chest,  shapely  arms  and  shoulders,  the  vigorous  trunk, 
and  erect  and  noble  carriage  of  the  Venuses  and  Junos,  Helens  and  Madon- 
nas, we  behold  a  vision  of  long  necks,  angular  shoulders,  of  sunken  chests, 
bulging  hips,  and  lean  legs,  as  in  the  "Prima  Vera." 

The  last  decade  has  witnessed  great  improvement  in  the  physique  of 
the  American  maiden  through  increased  devotion  to  out-of-door  sports,  and 
today  the  vestmental  deformities  are  in  many  instances  largely  overcome, 
and  the  luxuriant  form,  damask  cheek,  and  brilliant  eye  denote  an  Ameri- 
can product  the  peers  of  their  hardy  trans-Atlantic  cousins. 

Still  another  comparison  can  be  made  by  the  study  of  the  human  form 
among  aborigines  untrammeled  by  clothing.  Even  here,  however,  the  heavy 
neck  ornaments  produce  deformity,  and  most  half-clothed  natives  show 
slight  pressure  signs,  produced  by  the  compression  of  the  cestus,  or  band 
about  the  waist. 

The    evil    effects    of    faulty    footwear    can    best    be    understood    by    a 


Fig.  31. — Torso  of  Venus,  Naples. 


Fig.  32. — Prima  Vera  (Botticelli). 


Fig.  23- — Venus  Cnidus  (Praxiteles). 


Fig.  34. — Venus  Geniteice,  Florence. 


Fig.  35. — Hermes  or  Praxiteles. 


Fig.  36. — Gladiator. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  37 

comparison  of  the  shoe-bound  foot  of  today  with  the  ideal  represented  by  the 
famous  foot  in  the  Hermes  of  Praxiteles.  In  this  the  inner  edge  is  straight, 
the  outer  edge  is  but  slightly  curved,  the  little  toe  is  neither  crumpled  nor 
twisted  and  lies  parallel  to  its  fellows.  Compression  of  the  foot  in  front  is 
the  most  common  deformity,  the  hallux  valgus  resulting  from  the  crowding 
outward  of  the  end  of  the  great  toe,  and  the  curling  downward  and  inward 
of  the  little  toe  from  lateral  pressure  made  by  a  too  narrow  shoe.  The  latter 
deformity,  at  first  from  the  pressure  of  the  cross-thong  and  later  from  the 
crowding  of  the  shoe,  has  been  universally  represented  in  art  since  the  sixth 
century  B.  C,  as  seen  in  the  Gladiator  and  other  famous  statues,  and  inves- 
tigation of  large  collections  of  shoes,  such  as  the  one  at  the  Chicago  World's 
Fair,  or  the  one  at  the  Musee  Cluny  in  Paris,  demonstrates  the  fact  that  de- 
formities of  the  feet  were  as  common  during  the  Dark  Ages  as  they  are  today. 
In  addition  to  hallux  valgus,  among  the  most  common  deformities  are  ham- 
mer-toe, overlapping  toe,  weakened  foot,  flat-foot,  injury  to  the  transverse 
arch,  and  crumpled  toe. 

Since  foot  deformities  occur  very  early  during  adolescence  it  is  exceed- 
ingly difficult  to  find  a  normal  foot  among  civilized  people;  and  when  found 
it  will  usually  be  discovered  that  the  possessor  has  not  worn  shoes  during 
this  period. 

A  classic  example  of  the  effect  of  pressure  in  producing  deformities  of 
the  feet  is  seen  in  the  ingenious  devices  for  bandaging  and  deforming  the  feet 
of  Chinese  women. 

Constitutional  Deformities. — Constitutional  diseases  are  responsible  for 
a  great  number  of  deformities,  the  most  important  of  which  are  tuberculosis, 
rickets,  osteomalacia,  osteitis  and  arthritis  deformans,  and  the  osteo-arthro- 
pathies  of  spinal  origin. 

Tuberculosis  bears  so  important  a  relation  to  the  production  of  deformi- 
ties that  an  entire  section  will  be  devoted  to  it. 

The  deformities  produced  by  rickets  include  lateral  curvature,  pigeon 
breast,  coxa  vara,  knock-knee,  bow-legs,  and  the  curvatures  of  the  diaphysis. 
The  mechanism  of  the  production  of  rachitic  deformities  is  well  understood. 
During  the  second  stage  of  bone  softening  the  superincumbent  weight  de- 
forms the  bones,  and  they  retain  this  deformed  shape  after  they  have  become 
consolidated  and  hardened  during  the  third  stage.  The  production  of  late 
rickets,  or  rachitis  tarda,  is  not  so  well  understood,  but  it  is  probably  due  to 
causes  similar  to  those  which  produce  infantile  rickets — faulty  nutrition. 


38 


ORTHOPEDIC  SURGERY. 


The  marked  deformities  which  are  produced  by  osteomalacia  are  the 
result  of  pressure  and  faulty  positions  assumed  by  the  individual  during  the 
stage  of  bone  softening.  The  etiology  of  this  affection  is  not  sufficiently  well 
understood,  but  with  careful  observation  two  forms  may  be  recognized — the 
infantile  and  the  senile  forms.  The  infantile  variety  is  exceedingly  rare,  but 
a  sufficient  number  of  cases  have  been  described  to  identify  the  affection,  and 
the  one  here  presented  illustrates  the  fact  that,  while  the  disease  is  very  crip- 
pling in  its  effect,  it  does  not  interfere  with  life.  The  changes  occurring  in 
the  osseous  system,  such  as  osteoporosis  and  universal  hyperostosis,  atrophy, 
etc.,  have  their  influence  upon  the  production  of  deformities.     Universal  hy- 


Fic.  37. — Osteomalacia  Intantilis. 


perostosis  is  the  most  rare  of  all  the  affections  of  the  bones,  and  the  specimen 
shown  in  Fig.  39  was  taken  from  a  lad  of  eighteen  suffering  from  hyperostosis 
combined  with  osteoporosis. 

The  lesions  in  osteitis  and  arthritis  deformans  are  so  universal  and  so 
frequent  that  they  are  very  well  understood,  and  the  manner  in  which  they 
deform  the  joints  is  easily  seen.  The  changes  which  occur  in  the  s\Tiovial 
membrane  involve  the  cartilages  and  the  joints  become  locked  in  splint-like 
osteophites  or  undergo  an  atrophy.  In  some  instances  the  softening  of  the 
bone  permits  of  a  change  in  the  angle  of  the  femur,  producing  a  senile  coxa 


Fig.  38. — Osteomalacia     X-Ray.    Right  Arm. 


Fig.  39.— Universal  Hyperostosis  WITH  OsTEo-  Fig.  40.— Rheumatoid  Arthritis  (Philadelphia 


POROSIS  (Philadelphia  College  of  Physicians) 


College  of  Ph3'sicians). 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


43 


vara,  while  in  others  the  changes  in  the  joints  from  the  overgrowth  of  the 
condyle  produce  a  change  in  the  angle  of  the  entire  joint,  as  in  the  elbow- 
joint  and  knee-joint. 

The  neuropathic  lesions  of  spinal  origin,  from  tabes  or  syringomyelia  and 
other  causes,  constitute  a  large  group  of  affections  which  are  instrumental 
in  producing  deformities.  The  deformities  due  to  cerebral  palsies  of  the 
hemiplegic,  diplegic,  and  paraplegic  types  constitute  an  important  group  of 

affections.  Those  deformi- 
ties produced  by  the  primary 
myopathies  are  included  in 
the  comprehensive  term  of 
"muscular  dystrophy,"  and 
present  a  large  group  of  wast- 


FiG.  41. — Osteitis  Deformans  Syphilitica. 


Fig.  42. — Genu  Recurvatum 
(Joachims  thai). 


ing  diseases,  such  as  simple  muscular  atrophy,  pseudo-hypertrophic  paralysis, 
progressive  muscular  atrophy,  etc.  Multiple  exostoses  occurring  in  children 
present  another  interesting  group,  and  the  resulting  deformities  are  being  care- 
fully investigated  at  the  present  time.  The  production  of  deformities  by  osteo- 
myelitis through  the  rarefaction  of  the  bones  deserves  notice,  since  it  gives  rise 
at  times  to  serious  deformity  of  the  joints.  An  excellent  example  of  this  is  seen 
in  the  contracture  of  the  knee-joint  from  overgrowth  of  the  femur. 


44 


ORTHOPEDIC  SURGERY. 


Trauma  as  an  Etiologic  Factor. — The  influence  of  trauma  as  a  causa- 
tive factor  in  the  production  of  non-tuberculous  joint  disease  is  supported 
by  statistical  evidence  and  clinical  observation.  Various  joint  lesions  are 
localized  by  slight  injury,  as  sprains  and  contusions,  while  their  absence  is 
frequently  noted  after  fracture.     They  are  more  apt  to  follow  slight  injuries 

than  those  of  a  more  severe  char- 
acter. Many  infectious  processes, 
such  as  an  acute  osteomyelitis, 
gonorrheal  arthritis,  and  syphilitic 


Fig.  43. — Ataxic  Joint. 


Fig.  44. — Deformity  of  Knee-joint  from 
Osteomyelitis  (Hoffa). 


periosteitis,  are  localized  by  traumatism.  Patients  who  are  subject  to  attacks  of 
acute  articular  rheumatism  are  very  apt  to  develop  a  very  severe  attack  and 
recover  more  slowly  after  they  have  sustained  a  moderate  injury  to  the  joint. 
While  it  is  impossible  to  see  what  relation  injury  bears  in  the  development  of  or 
in  aggravating  the  arthropathies  of  the  nervous  system,  yet  it  frequently  hap- 
pens that  such  an  attack  is  first  ascribed  to  injury,  and  if  the  condition  becomes 


1 
\ 
I 


Fig.  45.— Progressive  Muscular  Fig.  46.— Exostoses  of  Vertebra  and  Ilia  (Philadel- 

Atrophy.  phia  College  of  Physicians). 


Fig.  47. — Exostoses  of  Femur  (Philadelphia  College  of  Physicians). 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  49 

worse,  it  is  usually  referable  to  some  previous  trauma.  The  neuro-patho- 
logic  condition  found  in  hysteric  joints  and  various  neuroses  following  trauma 
is  not  well  understood  at  present.     The  symptoms  present  in  these  cases  are 


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Fig.  48. — Infective  Osteomyelitis  (Philadelphia  College  of  Physicians). 

entirely  out  of  proportion  to  the  extent  of  the  injury,  and  at  first  lead  one  to 
consider  that  some  grave  lesion  is  present. 

Contractures  and  Ankylosis. — A  large  number  of  deformities  are  pro- 


50  ORTHOPEDIC  SURGERY. 

duced  by  contractures,  and  there  are  different  ways  of  subdividing  this  vari- 
ety of  deformities.  It  has  been  divided  in  the  same  manner  as  that  of  the 
general  classification  of  deformities,  under  the  head  of  traumatic,  static,  con- 
stitutional, and  inflammatory;  but  the  best  classification  is  that  of  Hoffa, 
which  divides  them  into  five  groups — contractures  of  the  skin,  contractures 
of  the  fascias  and  tendons,  contractures  of  the  muscles,  contractures  from 
nervous  lesions,  and  joint  contractures. 

The  most  common  cause  of  contracture  of  the  skin  is  from  exten- 
sive scalds,  burns,  or  lacerated  wounds.  The  cicatricial  contraction  which 
always  follows  these  lesions  produces  severe  contractures  of  the  adjoining 
parts.  Thus,  we  have  contractures  of  the  fingers,  wry-neck,  club-foot,  and 
contractures  about  the  larger  joints.  When  the  burns  or  scalds  are  of  the 
third  degree,  involving  the  fascias  and  tendons,  we  have  some  severe  con- 
tractions resulting.  In  certain  conditions,  as  Dupuytren's  contraction,  chronic 
rheumatism  in  some  forms,  and  in  skin  diseases,  we  have  contractures 
of  the  fascias.  Under  the  head  of  contractures  of  the  tendons  should  be 
considered  the  contractions  which  occur  from  the  inflammatory  conditions, 
such  as  tenositis  and  tenosynovitis. 

The  contractures  which  occur  from  muscular  action  are  of  two  varie- 
ties, the  passive  and  the  active.  Those  which  are  passive  include  cases 
which  are  due  to  the  contraction  of  one  group  of  muscles,  the  other  muscles 
being  stretched,  as  in  club-foot.  The  symptomatic  forms  are  the  result  of 
rheumatism  and  general  inflammatory  conditions.  In  contractures  from 
rheumatism  the  muscles  principally  involved  are  the  pectoralis  major,  latis- 
simus  dorsi,  deltoid,  occipitofrontalis,  trapezius,  and  the  intercostals  and 
quadratus  lumborum.  We  also  have  muscular  contractions  from  the  inter- 
ference with  the  articular  circulation  from  pressure  of  bandages  or  from  dis- 
ease of  the  vessels.  The  occurrence  of  syphilitic  gummas  in  the  muscles, 
particularly  in  the  sternomastoid  or  biceps,  leads  to  contraction  of  these  struc- 
tures, and  psoas  contraction  frequently  occurs  from  a  rupture  of  the  fibers 
with  cicatricial  contraction,  following  abscess. 

The  muscular  structure  is  subject  to  several  different  inflammatory 
processes  which  result  in  contractures.  Thus,  we  have  a  primary  form  of 
poliomyelitis  which  is  sometimes  combined  with  polyneuritis  and  is  loiown 
as  neuromyositis.  The  degenerative  conditions  which  occur  in  the  fibers 
frequently  cause  a  condition  known  as  myositis  fibrosa,  or  true  bony  structure 
may  be  deposited  in  the  muscles,  a  condition  known  as  myositis  ossificans. 


Fig.  49. — Muscular  Contraction  trom  Osteosarcoma  of  the  Vertebras. 


Fig.  50. — X-Ray  of  Same  Case. 


Fig.  51. — Ankylosis  of  Knee-joint. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  55 

Other  diseases  of  the  muscles  resulting  in  contractures  include  abscesses  from 
hematomas  or  metastatic  abscesses  from  pyemia,  the  inflammatory  changes 
resulting  from  tuberculosis,  actinomycosis,  scarlatina,  gonorrhea,  and  trich- 
inosis. 

The  contractures  which  occur  from  nerve  lesions  may  be  reflex,  paraly- 
tic, or  spastic.  The  reflex  contractures  usually  result  from  joint  diseases, 
such  as  tuberculosis,  chronic  rheumatism,  and  neuropathies.  The  paralytic 
contractures  are  the  result  of  lesions  to  the  central  or  peripheral  nervous 
system  throughout  its  entire  extent.  Lesions  of  the  brain,  encephalitis, 
from  apoplexy  and  tuberculosis,  or  from  tumors,  frequently  have  contrac- 
ture of  parts  associated  with  them.  All  the  degenerative  cord  lesions  also 
have  contractures  associated  with  them.  The  contractures  from  poliomye- 
litis result  from  three  factors — the  opposition  of  the  normal  muscles  to  the 


Fig.  52. — Ankylosis  of  Elbow  from  Excessive  Callus  (Jones). 

paralyzed  muscles,  the  stretching  of  the  paralyzed  muscles  from  the  weight 
of  the  part,  and  the  growth  of  the  bones  and  joints,  the  paralyzed  muscles 
remaining  unchanged.  A  very  frequent  source  of  contracture  is  injury  to 
the  spinal  cord  from  traumatism;  the  meninges  may  be  torn,  giving  rise  to 
minute  punctate  hemorrhages  or  to  extensive  extravasations  of  blood — hema- 
torrhachis.  These  often  remain  long  after  the  injury  caused  by  the  contrac- 
ture or  dislocation  has  disappeared,  and  they  sometimes  persist  after  all 
pressure  has  been  removed  by  laminectomy.  Contractures  from  spinal  menin- 
gitis, either  infective  or  resulting  from  tubercular  caries  in  its  late  stage,  or 
from  pressure  of  tumors,  as  osteosarcoma  of  the  vertebras,  are  frequently 
very  persistent.  The  lesions  of  the  peripheral  nervous  system,  such  as  neu- 
ritis or  pressure  palsies,  progressive  nerve  atrophy,  hysteric  paralysis,  and 
paralyses  following  erysipelas  or  lead  poisoning,  are  all  fruitful  sources  of 
contractures.     The  contractures  of  a  spastic  character  which  occur  from  cere- 


56 


ORTHOPEDIC  SURGERY. 


bral  lesions  include  three  different  principal  groups,  according  to  their  dis- 
tribution, in  the  order  of  their  frequency — the 
hemiplegic,  the  diplegic,  and  the  paraplegic.  In 
addition  to  the  paralysis  in  these  cases  we  have 
a  fourth  group — a  condition  in  which  a  spasmodic 
character  is  added  to  the  contracture,  and  known 
as  athetosis. 

The  joint  contractures  are  the  result  of 
lesions  to  the  soft  structures  about  the  joints, 
the  fascias,  capsule,  and  s}Tio\dal  membrane. 
The  involvement  of  these  structures  is  usually 
secondary  to  disease  of  the  bones,  or  they 
may  be  infected  by  injuries  which  are  not  of 
sufficient  severity  to  involve  the  bones.  They 
may  also  be  affected  by  inflammatory  pro- 
cesses, infective  usually,  such  as  gonorrhea,  sup- 
purative synovitis,  rheumatism,  and  acute  poly- 
arthritis. 

Ankylosis. — The  deformities  resulting  from 
ankylosis  are  very  common  sequels  of  the  va- 
rious joint  lesions.  Of  these,  two  forms  are 
recognized — the  false  and  the  true.  In  false 
ank34osis  the  soft  structures  only  are  involved 
and  the  union  is  not  complete,  while  in  the 
true  the  articulating  bones  are  closely  united. 
In  false  ankylosis  the  part  is  usually  deformed 
in  flexion  or  with  the  limb  in  a  position  of 
adduction  and  pronation.  In  true  ankylosis  the 
joint  surfaces  are  firmly  united  by  fibrous  tis- 
sue or  by  bony  tissue  or  sometimes  by  osteo- 
phytes, in  some  instances  the  bony  structure 
being  continuous  between  the  articulating  sur- 
faces. This  condition  is  known  as  ankylosis 
fibrosa,  ankylosis  ossia,  s}'nostose,  syndesmose, 
etc.  The  causes  of  true  ankylosis  are  tubercu- 
losis and  other  chronic  destructive  inflammatory  processes.  Tuberculosis 
of   the   joints   is   a   frequent    source   of    ankylosis.      In    some    instances    it 


PH 

^Hv^M/^B 

^K^  V^^^^^^l 

■-..'IV^ 

IH 

^^Ht'iJi'.HH 

kI 

|^^i.'.A  ^H 

^■nT  iui 

^;  fl 

^^■iU^  kUjI 

M  fl 

m 

11 

|fl 

■rltl 

^m:  %m 

Wfm 

^^^^^^B 

&S 

mi 

Fig.  53. — .■\n-kylosis  of  Axkle 
Joint  from  Osteomyelitis 
(Philadelphia  College  of  Phy- 
sicians). 


M  z; 
I 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


59 


results    in    true    bony  ankylosis    from    the   deposit   of   osteophytes    and   the 
union    of    the    eroded    surfaces    of    the    bone.       In    other    instances     false 


Fig.    56.  —  Ankylosis    of    Rib    and      Fig.    57. — Ankylosis    or    Vertebra 
Vertebra    (Wistar    Institute    of  and  Sacrum  (Wistar  Institute  of 

Anatomy).  Anatomy). 

ankylosis  results,  the  bony  surfaces  not  being  sufficiently  eroded   to  produce 
true  ankylosis,  but  the  deposit  of  fibrous  tissue  being  excessive. 


GENERAL    ETIOLOGY,    PATHOLOGY,    AND    TREATMENT    OF   TUBER- 
CULOUS  JOINT   DISEASE. 

Tuberculous  Joint  Disease. 

Synonyms. — English,  strumous  joint  disease;  scrofulous  joint  disease; 
fungous  joint  disease;  tuberculous  ostitis;  tuberculous  osteomyelitis;  tu- 
berculous disease  of  joints;  white  swelling;  tuberculous  arthritis.  German, 
scrofulose  Gelenkentziindung;  scrofulose  caries;  tuberculose  caries;  Gelenk- 
tuberculose;  fungose  arthritis.  French,  osteo-periostite  tuberculose  chronique; 
tubercule  tardif  a  evolution  rapide;  tuberculose  chronique;  tuberculose 
articulaire.    Italian,  caries  mollis  sive  fungosa;  caries  sicca;   fungus  articuli. 

Etiology. — The   etiologic   factor  of  tuberculous  joint  disease  was  first 


60  ORTHOPEDIC  SURGERY. 

definitely  ascertained  through  the  discovery  of  the  presence  of  the  tubercle 
bacillus  in  chronic  diseases  of  the  joints  by  Koch  in  1882.  He  proved  con- 
clusively that  the  same  agent  was  at  work  in  the  production  of  the  pathologic 
changes  found  in  chronic  joint  disease  as  caused  tuberculous  lesions  in  other 
parts  of  the  body.  The  similarity  between  certain  forms  of  chronic  joint 
disease  and  "tubercular"  lesions  of  other  parts  was  first  suggested  by  Roki- 
tanski  in  1844.  Virchow  considered  that  the  joint  lesions  were  due  to  miliary 
tubercles  affecting  the  synovial  membrane,  and  Volkmann  pointed  out  small 
tubercles  in  the  synovial  membrane.  Hiiter  and  Schiiller  experimentally  pro- 
duced tuberculous  lesions  of  joints  in  animals  after  inoculation  and  local  injury. 

Causes  Predisposing  to  Tuberculous  Joint  Lesions. — The  large  pro- 
portion of  cases  having  tuberculous  joint  lesions  is  due  to  certain  causes 
which  favor  the  growth  of  the  tubercle  bacilli  about  the  joints.  These  fac- 
tors may  be  divided  into  general  and  local  causes.  The  general  predispos- 
ing causes  may  be  considered  as  inherited  and  acquired. 

Inherited  Predisposition. — That  there  exists  among  certain  races  a 
tendency  to  the  occurrence  of  tuberculosis  is  well  known.  This  is  especially 
shown  in  the  colored  race.  Children  of  tuberculous  parents  are  very  prone 
to  develop  a  similar  condition  either  of  a  visceral  or  an  arthritic  variety.  It 
has  long  been  a  debatable  question  as  to  whether  direct  infection  can  occur 
before  birth.  Many  authorities  claim  that  congenital  tuberculosis  does  not 
exist.  This,  however,  has  been  disproved  by  the  demonstrations  of  tuber- 
culous hip-joint  disease  in  the  fetus  and  newborn  by  Morel-Lavalle,  Mar- 
jolin,  and  Leon  Labbe  (Hoffa). 

That  heredity  plays  a  very  important  part  in  predisposing  to  tubercu- 
lous joint  disease  has  long  been  admitted.  Statistics  on  the  subject  are  nu- 
merous, and  while  it  is  impossible  to  have  any  uniformity  in  the  percentage 
rate,  yet  the  foremost  authorities  agree  as  to  the  role  played  by  heredity.  In 
the  great  majority  of  cases  the  hereditary  predisposition  can  be  traced  to  the 
father  of  the  patient.  This  is  strikingly  shown  by  the  number  of  patients 
who  are  brought  to  hospitals  by  their  mothers,  who  are  generally  anemic, 
and  who  generally  state,  if  a  truthful  history  is  given,  that  the  father  died  of 
phthisis  or  some  other  form  of  tuberculosis.  The  difficulty  of  arriving  at  any 
correct  statistics  as  to  the  part  heredity  plays  in  the  production  of  tuberculous 
joint  disease  can  readily  be  understood  by  the  misstatements  made  by  par- 
ents and  relatives  of  patients  in  regard  to  the  family  history.  It  is  a  note- 
worthy fact  that  the  cause  of  joint  disease  is  usually  ascribed  to  traumatism 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  61 

by  parents,  relatives,  and  friends.  All  statistics  should  therefore  represent 
at  least  the  minimum  percentage  of  cases  having  a  hereditary  tendency. 

Acquired  Predisposition. — Among  certain  classes  there  is  an  acquired 
predisposition  to  the  development  of  tuberculous  joint  disease.  Any  con- 
dition which  lowers  the  general  resistance  of  the  patient  predisposes  to  tuber- 
culous joint  disease.  It  is  a  well-known  fact  that  in  apparently  healthy  in- 
dividuals there  have  been  found  at  autopsy  evidences  of  tuberculosis  of  the 
bronchial  and  mesenteric  lymph-nodes.  This  is  known  as  latent  tubercu- 
losis, and  it  only  requires  some  favorable  general  or  local  condition  for  the 
focus  to  develop  into  active  tuberculous  processes  throughout  the  body. 
Among  the  conditions  predisposing  to  acquired  tuberculosis  may  be  men- 
tioned poor  hygienic  surroundings,  bad  air,  absence  of  sunlight,  improper 
food,  and  principally  infectious  diseases,  which  rapidly  lower  the  vital  resis- 
tance. The  great  prevalence  of  tuberculosis  in  thickly  populated  cities  where 
people  are  closely  housed,  use  food  of  a  poor  quality,  and  pay  little  heed  to 
the  laws  of  hygiene  is  so  well  known  as  to  require  little  comment. 

Local  Predisposition — Traumatism. — Among  the  local  predisposing 
causes,  traumatism  plays  a  great  part.  Most  patients  give  a  history  of  having 
injured  the  involved  joint  at  some  previous  time,  and  naturally  assert  that  the 
condition  is  due  to  traumatism.  These  injuries  are  generally  of  a  mild 
nature  and  cause  very  little,  if  any,  inconvenience  at  the  time.  It  has  been 
shown  experimentally  by  Krause  and  others  that  tuberculous  joint  disease 
generally  follows  only  moderate  injury.  By  inoculating  susceptible  animals 
with  tuberculous  material  and  then  contusing  various  joints  Krause  was 
able  to  produce  typical  joint  lesions.  When  the  traumatism  was  severe, 
as  in  fractures,  he  found  that  secondary  involvement  of  the  joint  did 
not  occur.  The  cause  of  this  is  explained  by  the  fact  that  following 
mild  injuries  local  congestion  occurs  during  the  course  of  repair,  which 
offers  suitable  soil  for  the  growth  of  the  tubercle  bacilh,  while  following  in- 
juries of  a  severe  nature  the  process  of  repair  is  so  active  that  the  tubercle 
bacilli  are  generally  destroyed.  The  statistics  on  the  local  predisposition 
caused  by  injury  are  interesting.  In  845  cases  C.  F.  Taylor  states  that  53 
per  cent,  were  due  to  injury.  Gibney  gives  42  per  cent,  in  an  analysis  of 
596  cases;  Croft,  35  per  cent.  Whitman  states  that  the  combined  statistics 
of  Hildebrand,  Konig,  Mikulicz,  and  Bruns  show  that  in  513  of  3398  cases 
of  tuberculous  disease  of  the  bones  and  joints  injury  seemed  to  be  a  direct 
predisposing  cause  of  the  local  disease.     Albrecht  considers  that  about  one- 


62  ORTHOPEDIC  SURGERY. 

sixth  of  all  tuberculous  joint  lesions  follow  injury.  The  statistics  showing 
the  infrequency  of  tuberculous  lesions  following  severe  joint  mjuries  bear 
out  the  statement  made  above.  In  845  cases  of  spinal  paralysis  occurring 
in  children  who,  on  account  of  the  disease,  are  constantly  subject  to  joint 
injury,  Gibney  states  that  in  only  four  instances  were  there  joint  diseases. 
In  100  cases  of  fracture  about  the  elbow  observed  by  Roser  there  resulted  no 
tuberculous  lesion. 

Static  Predisposition. — The  greater  liabihty  to  the  development  of 
tuberculous  lesions  in  the  joints  of  the  lower  extremities  as  compared  with 
those  of  the  upper  extremities  is  explained  by  the  greater  liability  of  the  joints 
of  the  former  to  injury  and  to  the  fact  that  they  are  required  to  bear  the 
weight  of  the  body  and  cannot  be  placed  at  rest  with  the  same  degree  of  ease 
without  requiring  the  patient  to  take  to  bed.  The  combined  statistics  of  the 
Boston  Children's,  Hospital,  the  Hospital  for  Ruptured  and  Crippled,  and 
Vanderbilt  Clinic,  those  of  Thorndike,  Cheyne,  Jaffe,  Schmalfuss,  Billroth, 
Mentzel,  and  Judson,  show  that,  in  a  great  number  of  cases,  the  lower  ex- 
tremity was  the  seat  of  tuberculous  joint  disease  in  57.6  per  cent.,  while  the 
joints  of  the  upper  extremity  were  affected  in  only  4  per  cent,  of  the  cases. 

Exanthemata. — To  the  acute  exanthemata  should  be  ascribed  in  a 
large  percentage  of  cases  the  production  of  tuberculous  joint  disease.  This 
is  particularly  evident  in  scarlet  fever  and  measles. 

Age. — A  very  great  proportion  of  cases  of  tuberculous  joint  disease 
occurs  in  childhood.  This  is  due  to  the  following  reasons:  (i)  The  greater 
liability  to  the  development  of  bone  disease  during  the  period  in  which  the 
osseous  structures  are  rapidly  growing  and  tissue  changes  are  very  rapid; 
(2)  during  early  life  children  are  especially  liable  to  slight  joint  injuries  oc- 
casioned by  repeated  falls;  and  (3)  more  people  are  alive  from  five  to  ten 
years  than  at  later  periods  of  life. 

Thorndike  has  observed  a  case  of  tuberculous  disease  of  the  hip  during 
the  first  week  of  life  and  several  cases  of  the  same  disease  of  the  spine  and 
hip  during  the  first  six  months. 

Knight's  statistics,  quoted  by  Whitman,  on  5461  cases  of  tuberculous 
disease  treated  at  the  Hospital  for  Ruptured  and  Crippled  show  that  about 
seven-eighths  of  the  patients  were  less  than  fourteen  years  of  age. 

r  Vertebras, 87.7  per  cent. 

Less  than  fourteen  years  of  age, -  Hip, 88.2       " 

C  Other  joints, 71.7        " 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


63 


r  Vertebras, 7-7  per  cent. 

Between  fourteen  and  twenty-one  years  of  age, .  I  Hip, 9.2 

V  Other  joints, 10.7        " 

r  Vertebras, 4.5        " 

More  than  twenty-one  years  of  age, \  Hip, 2.5 

C  Other  joints, 17.5        " 

Gibney  reported  S60  cases  of  tuberculous  joint  disease,  of  which  84.5 
per  cent,  occurred  before  fourteen  years  of  age.  In  1344  cases  of  hip-joint 
disease  from  the  combined  statistics  of  Wright,  Bryant,  and  Sayre  there  were 
1000  occurred  before  the  fifteenth  year. 

Sex. — While  sex  plays  but  little  part  in  the  occurrence  of  tuberculous  joint 
diseases,  males  are  affected  more  frequently  than  females,  the  cause  being  the 
greater  liability  to  injury  among  boys,  who,  as  a  rule,  lead  a  more  active  life. 

The  combined  statistics  of  Konig  and  Gibney  show  that  in  1 218  cases  of  tuber- 
culous knee-joint  disease,  there  were  703,  or  57.6  per  cent.,  occurred  in  males. 

Side  Affected. — The  right  side  is  slightly  more  frequently  affected  by 
tuberculous  joint  disease.  This  is  accounted  for  by  the  fact  that  the  great 
majority  of  people  use  the  right  side  more  frequently  than  the  left.  The 
part  injury  plays  as  a  predisposing  factor  is  well  shown  by  the  relative  fre- 
quency of  joint  lesions  occurring  in  the  right  upper  extremity  as  compared 
with  the  left  lower  extremity.  Most  people  are  right-handed,  and  necessarily 
injure  the  right  upper  extremity  more  often  than  the  left.  Yet  the  difference  in 
training  between  the  two  lower  extremities  is  never  marked,  and  on  this  account 
very  little  difference  is  shown  in  the  side  affected  in  the  lower  extremities. 

Distribution  of  Tuberculous  Joint  Disease. — The  following  combined 
statistics  show  the  relative  frequency  with  which  the  various  joints  are  involved : 


Vertebras, . 

Hip, 

Knee, 

Ankle,  ... 
Elbow,.... 
Shoulder, . 

Wrist, 

Total, 


Gibney 
(Mostly  1 
IN  Chil- 
dren). 


209 
271 
i°3 
31 


614 


Boston 

Hospital 
FOE  Rot- 

Children's 

New  York 

Cheyne 

Hospital, 

(Under 

Crippled 
(Whitman)  . 

(Bradi-ord 

PEDic  Dis- 

Ten 

Dep't. 

Judson. 

AND 

pensary. 

Years). 

(THORNDTin^) 

Lovett). 

(Under  Two 

Years). 

1432 

1964 

1024 

78 

120 

577 

5404 

I123 

1402 

I178 

44 

61 

4079 

699 

104 

319 

24 

29 

181 

I4S9 

196 

300 

83 

4 

614 

62 

IS 

II 

13 

8 

109 

42 

15 

II 

2 

6 

76 

7 

20 

7 

2 

36 

3561 

3820 

2633 

167 

210 

772 

11.777 

46.7 

34-4 
12.2 

S-i 
0.8 

°-s 

0-3 

lOO.O 


Polyarticular  Joint  Disease. — Tuberculous  disease  may  affect  several 
joints  at  the  same  time,  or  one  joint  may  be  involved  and  shortly  after  a 


64  ORTHOPEDIC  SURGERY. 

second  joint  is  affected  by  the  same  process.  It  is  rare  to  have  tuberculous 
disease  of  two  similar  joints,  as  double  hip  disease,  or  knee-joint  disease. 
Simultaneous  involvement  of  the  hip  and  spine  and  of  the  knee  and  spine 
are  the  most  frequent  forms  of  double  disease.  The  knee-joint  and  wrist- 
joint  and  the  hip-joint  and  wrist-joint  are  occasionally  the  seat  of  tubercu- 
lous disease  at  the  same  time.     Double  tumor  albus  is  very  rarely  seen. 

Avenues  of  Infection. — Tuberculous  joint  disease  is  usually  secondary 
to  other  foci  in  the  body,  although  cases  are  reported  in  which  no  other  foci 
could  be  found  after  the  most  careful  search.  The  latter  class  of  cases  may 
be  due  to  direct  infection  taking  place  through  the  blood  folloAving  wound 
infection.  There  are  various  avenues  by  which  the  tubercle  bacilli  may  gain 
entrance  into  the  body  and  set  up  primary  foci  of  disease.  They  may  be 
divided  broadly  into  two  classes:  (i)  Infection  through  the  respiratory  tract, 
and  (2)  infection  through  the  alimentary  tract.  Primary  foci  following  in- 
fection by  the  respiratory  tract  are  seen  in  the  development  of  tuberculous 
bronchial  and  cervical  glands,  and  following  infection  by  the  alimentary  tract 
are  seen  in  the  development  of  tuberculous  mesenteric  glands.  In  a  great 
majority  of  cases,  how^ever,  there  are  no  clinical  signs  of  tuberculosis  with 
the  exception  of  enlarged  cervical  glands,  as  the  disease  very  often  remains 
quiescent  and  does  not  set  up  secondary  foci  in  the  viscera  or  osseous  system. 
When  the  general  surroundings,  however,  are  poor  and  there  occur  causes 
which  lower  the  vital  resistance  of  the  individual,  secondary  foci  are  very 
liable  to  develop.  This  is  especially  seen  in  cases  having  a  hereditary  ten- 
dency, in  cases  which  have  a  lowered  vitality  following  infectious  fevers,  and 
in  cases  subject  to  mild  traumatism.  Following  these  predisposing  causes 
visceral  and  joint  tuberculosis  is  very  prone  to  develop.  That  tuberculosis 
is  secondary  to  primary  foci  in  the  lymphatic  system  the  statistics  of  StUl, 
based  on  autopsies  performed  on  children  under  twelve  years  of  age  at  the 
Hospital  for  Children,  Great  Ormond  Street,  London,  show  very  conclusively. 
He  states  that  in  769  autopsies  there  were  269  cases  which  showed  the  pres- 
ence of  tuberculous  lesions.  His  table  of  statistics  giving  the  avenues  of  in- 
fection is  as  follows: 

Respiratory : 

Lungs, 105 

Probably  lungs, 33 

Ear, 9 

Probably  ear, 6 

153  =  57  percent. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  65 

Alimentary : 

Intestines, 53 

Probably  intestines, 10 

63  =  23.4  per  cent. 
Other  cases: 

Bones  or  joints, 5 

Fauces, 2 

Uncertain, 46 

53  =  19.6  per  cent. 

The  statistics  of  Northrup  and  Bovaird,  based  on  200  cases  treated  at 
the  New  York  Foundhng  Hospital,  are  as  follows: 

Infection  by  respiratory  tract, 148 

Infection  by  mesenteric  lymph-nodes, 4 

Indeterminate, 48 

200 

It  is  generally  possible,  in  cases  that  come  to  the  autopsy  table  in  which 
there  is  tuberculous  joint  disease,  to  find  the  primary  foci  in  some  set  of 
lymph-nodes.  This  is  usually  determined  by  the  advanced  state  of  the 
tuberculous  process  in  the  nodes.  Haushalter  found  the  tracheo-bronchial 
glands  to  be  the  primary  foci  in  74  instances  of  78  cases  of  autopsy  per- 
formed in  children  who  died  from  acute  miliary  tuberculosis.  That  a  pri- 
mary focus  cannot  always  be  found  is  shown  by  the  statement  of  Konig  that 
he  was  unable  to  locate  a  primary  focus  in  14  instances  of  67  autopsies  per- 
formed on  patients  who  had  tuberculous  lesions  of  the  bones  and  joints. 

Accidental  Inoculation. — That  inoculation  occurs  in  man  by  means 
of  the  implanation  of  the  bovine  tubercle  bacillus  has  been  proved  by  numer- 
ous experiments.  The  cases  of  Walley,  of  Edinburgh,  and  Moses,  of  Weimer, 
which  ended  fatally  followed  accidental  inoculation  with  the  bovine  bacillus. 
Bovine  tuberculosis  is  transmissible  to  man  by  direct  inoculation  and  through 
the  mediurn  of  food,  especially  milk.  A  case  is  cited  by  Pfeiffer,  of  a  veter- 
inary surgeon  with  a  negative  previous  tuberculous  family  history,  who  re- 
ceived a  wound  of  the  thumb  while  dissecting  a  tuberculous  cow,  developed 
a  tuberculous  joint  lesion  of  the  thumb,  and  died  in  a  year  and  a  half  from 
pulmonary  tuberculosis.  Professor  Lassar  has  observed  four  cases  of  "ver- 
rucose  tuberculosis"  of  the  skin  in  butchers,  which  he  was  inclined  to  believe 
were  due  to  bovine  tuberculosis.  E.  W.  Watson  considers  that  infection 
from  transmission  from  cattle  occurs  more  frequently  than  by  the  inhalation 


66  ORTHOPEDIC  SURGERY. 

of  dust  containing  the  tubercle  bacilli.  Another  means  of  accidental  inocu- 
lation is  cited  by  Lehmann.  He  states  that  he  has  seen  ten  cases  of  tuber- 
culous infection  occur  in  children  who  had  been  circumcised  by  a  rabbi 
who  had  active  phthisis.  Of  the  ten  cases  seen,  seven  died.  Cases  of  the 
same  nature  are  reported  by  Elsenberg,  Mecklen,  and  Hoist. 

Pathology. 

Presence  of  a  Primary  Focus. — In  the  majority  of  cases  of  tubercu- 
lous joint  disease  that  come  to  autopsy  there  can  be  found  a  primary  foci  of 
infection  elsewhere  in  the  body.  This,  as  stated  above,  may  be  in  the  res- 
piratory or  alimentary  tract  or  in  the  lymph-nodes  connected  with  these  two 
systems.  It  occasionally  occurs,  however,  that  the  most  careful  autopsy 
examination  fails  to  reveal  another  focus  in  the  body  that  can  undoubtedly 
be  considered  to  be  the  primary  seat  of  tuberculosis.  There  may  be  tuber- 
culous joint  or  bone  disease  with  very  extensive  lesions,  and  yet  there  may 
be  no  involvement  of  the  viscera  or  lymph-nodes.  Nichols  cites  a  case  which 
at  autopsy  showed  advanced  tuberculosis  of  the  vertebras,  combined  with 
a  large  psoas  abscess  opening  into  the  cecum  and  with  marked  amyloid  dis- 
ease of  the  liver,  spleen,  and  kidneys,  yet  there  could  be  found  no  evidence 
of  tuberculous  involvement  of  the  viscera  or  lymph-nodes.  In  this  class  of 
cases  the  osseous  lesion  must  be  considered  primary,  and  the  avenue  of  en- 
trance may  occur  through  an  abrasion  of  the  skin  or  mucous  membrane  and 
infection  occur  directly  through  the  blood  in  the  bone  without  causing  a  tuber- 
culous lesion  at  the  point  of  entry.  We  must  therefore  consider  that,  while 
tuberculous  disease  of  the  bones  and  joints  is  usually  secondary  to  a  focus 
elsewhere  in  the  body,  it  occasionally  happens  that  the  osseous  lesion  is 
beyond  doubt  primary. 

Formation  of  the  Osseous  Focus. — The  pathologic  changes  that  take 
place  in  the  bones  and  joints  are  essentially  productive,  exudative,  and  ne- 
crotic in  character.  The  tubercle  bacillus,  after  being  carried  from  pri- 
mary foci  or  being  introduced  directly  from  the  outside,  is  deposited  in  the 
bone-marrow  of  the  epiphysis.  This  deposit  usually  takes  place  in  the  epi- 
physeal line  to  the  diaphyseal  side  of  the  cartilage;  next  in  order,  at  the  epi- 
physeal side  of  the  cartilage;  occasionally  near  the  articular  cartilage;  and 
very  rarely  in  the  periosteum.  As  the  bacilU  lodge  in  moderate  numbers 
their  toxins  produce  as  one  of  the  early  effects  a  marked  proliferation  of  the 
connective  tissue  and  endothelial  cells.     The  latter  are  sometimes  known  as 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


67 


■/^ 


"epithelioid"  cells.  There  occur  along  with  this  proliferation  of  connective 
tissue  and  endothelial  cells  a  marked  emigration  of  leukocytes  and  extravasa- 
tion of  serum  and  multinuclear  or  "giant"  cells.  The  endothelial  cells  con- 
sist of  large  oval  nuclei  and  indistinct  granular  protoplasm.  The  multinuclear 
cells  contain  from  twenty  to  thirty  vesicular  nuclei  which  may  be  grouped  m. 
two  ways,  having  either  a  "bipolar"  or  a  "mural"  arrangement.  The  center 
of  these  multinuclear  cells  is  usually 
finely  granular  or  necrotic  and  does 
not  stain  distinctly.  Both  the  endo- 
thelial and  multinuclear  cells  have  a 
phagocytic  action.  Generally  there 
form  in  and  about  the  tubercu- 
lous area  numerous  small  spheroidal 
mononuclear  or  "lymphoid"  cells. 
These  mononuclear  cells  have  a  small, 
deeply  staining  nucleus  surrounded  by 
a  small  amount  of  indistinct  proto- 
plasm. The  stroma  connecting  the 
cells  is  made  up  of  processes  from 
the  endothelial  and  multinuclear  ceUs. 
Blood-vessels  are  not  apt  to  develop 
under  the  influence  of  the  tubercle 
bacUli,  the  old  blood-vessels  being 
obliterated  as  the  new  tissue  forms. 
The  formation  of  the  tubercle  there- 
fore consists  of  endothelial  and 
multinuclear  cells  surrounded  by  the 
small  spheroidal  mononuclear  cells. 
As  the  tubercle  enlarges  there  occurs 
a  damage  to  cells  and  tissue  which 
leads  to    coagulation    necrosis,    first 

manifested  in  the  center  and  progressing  outward.  The  nuclei  of  the  cells 
became  fragmented  or  disappear,  fail  to  stain,  the  protoplasm  becomes  homo- 
geneous, the  cells  and  stroma  forming  at  last  an  hregular  mass  of  tissue  de- 
tritus in  which  are  seen  small  areas  of  fat.  This  condition  is  known  as  casea- 
tion or  coagulation  necrosis.  As  this  state  advances  the  gray  translucent 
appearance  which  the  early  tubercle  presents  becomes  opaque  and  yellowish- 


Tuberculous  focus  in  end  of  femur. 

Fig.  58. — Tuberculous  Focus  in  Femur  (Nichols). 


ORTHOPEDIC  SURGERY 


white  in  the  center.     Within  the  tubercles  there  are  found  in  small  numbers 
the  tubercle  bacilli,  which  may  be  present  in  the  cells  or  in  the  stroma. 

By  multiplication  and  extension  of  the  tubercle  bacilli  new  tubercles  are 
formed  about  the  original  deposit.     These  coalesce  and  enlarge  until  large 

tuberculous     areas     are     formed. 
,  ,--.-^v  '  While  the  process  of  tubercle  for- 

■  -   --■" '  -  mation  occurs,   the  tissues  about 

become  congested,  owing  to  an 
effort  of  nature  to  wall  off  the 
tuberculous  area  which  is  acting 
as  a  foreign  body.  A  poorly 
nourished  edematous  granulation 
tissue  is  formed,  which  contains 
numerous  small  blood-vessels  and 
"plasma"  or  "lymphoid"  cells. 
These  latter  cells  are  generally 
rounded  or  polyhedral,  about  the 
size  of  a  leukocyte,  having  a  round 
or  oval  nucleus  which  is  eccentri- 
cally placed,  showing  irregular 
groupings  of  chromatin,  the  body 
of  the  cell  being  characterized  by 
the  staining  of  its  protoplasm  with 
basic  anilin  dyes.  Usually  this 
feebly  nourished  granulation  tissue 
becomes  readily  infected  with  the 
tubercle  bacilli  and  rapidly  under- 
goes the  changes  noted  above  in 
the  formation  of  tubercles.  As 
the  process  extends  the  peripher- 
ally placed  granulation  tissue  in- 


<^^:^ 


Fig.   59.- 


-Solitary  Early   Tubercle  in  Bone-mar- 
row (Nichols). 


vades  the  cancellous  structure  of 
the  bone  and  produces  either  a  partial  absorption  of  the  trabecules,  or,  if  the 
process  is  very  rapid,  the  structure  of  the  bone  is  retained  but  sequestra  are 
formed. 

Bone  Abscess. — As  new  tubercles  are  rapidly  formed,  liquefaction  ne- 
crosis takes  place  in  the  center  of  the  diseased  area,  the  trabecule  become 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY 


69 


softened,  necrotic,  and  are  gradually  set  free  in  a  central  cavity  which  is 
made  up  of  surrounding  granulation  tissue  and  is  known  as  a  "bone  abscess." 
This  abscess  has  a  well-defined  membrane  and  consists  of  purplish-red  gran- 
ulation tissue  in  which  are  numerous  tubercles.  Extending  around  this  mem- 
brane there    is    considerable  infiltration  of  marrow  spaces  with    edematous 


Fig.  6o. — Tuberculous  Dorsal  Abscess  of  Spine  (Schulthess). 
a,  a,  Aorta;  b,  adherent  lung. 


connective  tissue.  The  inner  layer  of  this  cavity  consists  of  tubercles  and 
granulation  tissue  in  all  stages  of  necrosis,  while  the  outer  layer  contains  tis- 
sue consisting  of  poorly  nourished  granulations  in  which,  as  a  result  of  the 
invasion  of  the  tubercle  bacilli,  tubercles  are  beginning  to  develop.  The  con- 
tents of  the  "bone  abscess"  consist  of  a  whitish-yellow  fluid  containing 
broken-down    granulation    tissue,    fragments    of    partially    dissolved     bone. 


70 


ORTHOPEDIC  SURGERY 


sequestra  of  various  sizes,  serum,  and  leukocytes.  Rarely  the  local  resistance 
is  effective,  and  then  the  granulations  contain  more  blood-vessels,  are  firmer 
and  better  nourished,  the  trabeculae  are  harder  and  more  resistant,  until 
finally  around  the  focus  there  occurs  a  peripheral  wall  of  granulation  tissue 
w^hich  shuts  in  the  diseased  area;  and  if  the  latter  is  small,  complete  absorp- 
tion  and  replacement   by   scar  tissue  take  place.     Generally,   however,   this 


Fig.  6i.— Lumbar  .Abscess  of  Spine  (Wistar  Institute  of  Anatomy). 

condition  does  not  occur,  but  instead  the  granulations  are  feeble,  contain  a 
small  proportion  of  blood-vessels,  the  local  resistance  is  very  poor,  no  sur- 
rounding wall  of  firm  granulation  tissue  occurs,  and  gradually  the  area  of 
disease  increases  by  continual  extension  of  deposits  of  tubercle  bacilli.  Co- 
incident with  this  extension  there  occurs  central  necrosis,  until  a  well-marked 
"bone  abscess,"  as  described  above,  occurs. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


71 


Sequestrum  Formation. — Occasionally,  however,  instead  of  produc- 
ing a  bone  "abscess"  the  tuberculous  lesion  consists  of  the  formation  of  a 
"sequestrum,"  or  an  irregular  area  of  necrotic  bone  which  lies  free  in  a  cav- 
ity of  the  bone.  This  "sequestrum"  is  produced  by  a  process  similar  to 
the  formation  of  an  abscess,  except  that  the  trabeculse  retain  their  shape,  and, 
while  they  become  necrotic,  do 
not  entirely  dissolve.  The  sur- 
rounding marrow  spaces  are 
filled  with  caseous  material.  The 
diseased  bone  over  a  consider- 
able area  finally  separates  from 
the  surrounding  structures  and 
remains  free  in  a  cavity,  the  walls 
of  which  contain  a  well-defined 
membrane  covered  with  numer- 
ous tubercles.  When  reparative 
changes  take  place  in  the  tuber- 
culous area,  the  walls  of  the 
cavity  become  dense,  sclerotic, 
and  finally  of  bony  consistence, 
and  the  sequestra  may  remain 
in  situ  for  years. 

Bone  Infarct. — When  tu- 
berculous epiphysitis  is  secon- 
dary to  a  focus  elsewhere,  it  is 
occasionally  seen  as  a  wedge- 
shaped  process  having  its  base 
directed  toward  the  articular  car- 
tilage and  its  apex  directed  to- 
ward the  epiphyseal  line.  Such 
an  arrangement  is  known  as  a 
"bone  infarct,"  and  is  similar  to 
an  infarct  occurring  in  other  organs,  being  due  to  the  lodgment  of  a  tubercular 
embolus  in  the  bone  artery  supplying  the  involved  portion  of  the  epiphysis. 

Terminations  of  an  Osseous  Focus.— Tuberculous  epiphysitis  may 
terminate  in  any  of  the  following  ways:  (i)  The  local  resistance  is  so  effec- 
tive that  the  focus  is  finally  surrounded  by  dense  fibrous  tissue,  and  if  small, 


Fig.  62. — Section  of  Cervical  Vertebras,  showing 
Sequestrum  (Schulthess). 

a,  Odontoid  process;  b,  cross-section  through  the  poste- 
rior border  of  foramen  magnum;  c,  cross-section  of 
the  atlas,  posterior  part;  d,  same,  anterior  portion. 


72  ORTHOPEDIC  SURGERY. 

may  be  absorbed,  or  if  large,  encapsulated;  (2)  extension  may  take  place  and 
perforation  occur  through  the  cortex  of  the  bone  outside  the  joint,  or  "extra- 
articular" perforation;  and  (3)  extension  may  take  place  and  perforation 
occur  inside  the  joint,  or  " intra-articular "  perforation. 

That  small  tuberculous  foci  occasionally  undergo  absorption  is  probably 
true,  although  Nichols  states  that  actual  demonstration  of  this  fact  is  very 
difficult.  When  it  does  occur,  the  focus  is  surrounded  by  firm,  well-nourished, 
granulation  tissue;  around  this  the  bony  structure  proliferates  and  incloses 
the  diseased  area,  and  if  this  is  small,  it  is  completely  absorbed  and  replaced 
by  scar  tissue;  if  the  area  is  comparatively  large,  it  becomes  encapsulated. 
Extra-articular  Perforation. — Frequently,  however,  the  diseased  pro- 
cess enlarges,  extends  to  and  perforates  the  cortex 
of  the  bone  extra-articularly,  and  subsequently  in- 
volves the  surrounding  soft  parts.  Extra-articular 
perforation  is  more  common  in  those  joints  in  which 
the  capsule  is  relatively  small  and  the  joints  are 
superficially  located.  This  is  especially  seen  in  such 
joints  as  the  knee,  elbow,  and  ankle.  In  those  joints 
that  are  deep  and  in  which  the  capsule  is  very  ex- 
tensive, as  the  hip,  shoulder,  and  where  the  bones  are 
in  close  contact  with  each  other  and  surrounded  gener- 

FiG.  63. — Tuberculous  Knee- 
joint,  SHOWING  Primary       ally  by  ligaments  SO  as  to  make  extra-articular  per- 

Area    of    Caseation    in 

THE     Epiphyseal    Line       foration  impossible,  as  the  spine,  intra-articular  in- 

(Nichols).  r  '  r        > 

a.  Epiphysis;  *,  primary  tuber-  Volvement    alwayS    OCCUrS. 

culous  focus:  c,  shaft.  ,-iii«i  t-v  ,.  -r^i,        . 

Cold  Abscess  Formation. — Followmg  perfora- 
tion of  the  cortex  and  periosteum  and  involvement  of  the  surrounding  soft  parts, 
a  tuberculous  or  "cold  abscess"  occurs.  Here  is  found  a  similar  but  more  rapid 
formation  of  secondary  tubercles  which  extend  peripherally  with  central  necrosis 
as  seen  in  involvement  of  the  cancellated  structure  of  bone.  These  abscesses 
spread  in  the  direction  of  least  resistance,  usually  in  the  intermuscular  septa. 
The  walls  of  this  abscess  are  of  a  grayish-yellow  color  and  the  surrounding  soft 
parts  consist  of  softened  tuberculous  tissue  around  which  is  poorly  nourished, 
edematous  granulation  tissue.  As  the  tuberculous  process  extends,  abscesses 
of  very  large  size  may  be  formed  which  travel  in  the  direction  of  least  resis- 
tance in  intermuscular  septa  until,  at  times  becoming  superficial  at  some 
distance  from  the  original  bony  focus,  they  perforate  the  skin  at  several  places 
and  partially  discharge  their  contents. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  73 

Contents  of  a  Cold  Abscess. — The  contents  of  a  tuberculous  abscess 
cavity  are  generally  composed  of  a  thin  whitish  occasionally  reddish  fluid, 
formed  from  the  remains  of  caseous  tubercles,  leukocytes,  fibrin,  serum,  and 
the  necrotic  remains  of  partially  destroyed  soft  and  bony  tissue.  The  reddish 
or  brown  color  which  is  occasionally  seen  is  due  to  fresh  or  decomposed  blood. 
Careful  search  with  the  microscope  will  generally  show  the  presence  of  the 
tubercle  bacilli  free  in  the  pus,  but  they  are  more  numerous  in  the  walls  of 
the  abscess.  Krause  considers  that  the  tubercle  bacilli  are  present  in  the 
contents  of  "cold  abscesses"  in  about  one-third  of  all  cases,  and  Nichols 
states  that  he  has  never  failed  to  produce  general  tuberculosis  in  suscept- 
ible animals — e.  g.,  guinea-pigs — after  inoculation  with  pus  from  these 
abscesses. 

Fistulas. — The  points  of  exit  of  these  abscesses  are  known  as  "tuber- 
culous fistulas,"  and  are  generally  several  in  number.  The  walls  of  the 
sinuses  are  composed  of  dense  tuberculous  tissue  surrounded  by  an  area  of 
granulation  tissue  of  bluish-white  color,  which  contains  very  few  blood- 
vessels and  is  readily  infected.  The  fistulas  are  irregularly  circular,  protuber- 
ant, and  generally  of  small  caliber  when  compared  with  that  of  the  sinuses 
with  which  they  are  continuous. 

Intra-articular  Perforation. — While  the  most  favorable  termination 
of  tuberculous  foci  is  absorption  or  encapsulation,  which  very  rarely  occurs, 
and  next  extra-articular  perforation,  which  occasionally  occurs,  the  most 
frequent  result  is  intra-articular  perforation  and  infection  of  the  entire 
synovial  membrane.  As  the  tuberculous  focus  within  the  epiphysis  in- 
creases in  size,  it  extends  peripherally  until  it  reaches  a  joint  just  beneath 
the  articular  cartilage.  Before  perforation  into  the  joint  takes  place  there 
occur  primary  changes  within  the  joint,  which  is  apparently  an  effort  of  nature 
to  limit  the  area  of  joint  involvement.  These  changes  consist  in  congestion 
and  hypertrophy  of  the  synovial  membrane,  moderate  effusion  into  the  joint 
cavity,  and  the  deposit  of  fibrin  upon  the  cartilage  and  synovialis.  These 
changes  usually  precede  perforation,  and  if  this  latter  does  not  occur,  there 
may  be  more  or  less  destruction  of  the  articular  cartilage  due  to  the  intra- 
articular changes.  The  cartilage  in  proximity  to  the  tuberculous  foci  rapidly 
disintegrates,  becomes  fibrous  and  yellow,  irregular  spaces  occur  through 
which  perforation  finally  takes  place  in  several  places,  and  the  cartilage  is 
either  destroyed  gradually  or  is  entirely  separated  from  the  underlying  bone 
by    the    tuberculous    process.      After    perforation    occurs    the    hypertrophied 


74 


ORTHOPEDIC  SURGERY. 


synovial  membrane  is  rapidly  covered  by  the  development  of  discrete  tuber- 
cles which  multiply  peripherally,  coalesce,  and  finally  produce  large  tuber- 
culous ulcers.  The  cartilage  may  be  destroyed  either  by  extension  of  the 
h\^ertrophied  synovial  membrane  in  a  pannus-like  growth,  causing  exten- 
sive ulcers  of  the  cartilage  and  successive  disintegration,  or  the  tuberculous 
process  extends  between  the  cartilage  and  bone,  separating  large  areas  of 
cartilage  from  the  underlying  bone,  leaving  beneath  bone  which  is  irregularly 


Fig.  64.— Tuberculous  Disease  of  Body  or  Vertebras  and  Intravertebral  Disease  (Wistar  Institute 

of  .\natomy). 


nodular  and  covered  with  tubercles  in  all  stages  of  coagulation  necrosis.  In 
time  there  may  remain  but  little,  if  any,  vestige  of  cartilage,  the  articulating 
ends  of  the  bones  become  markedly  eroded,  irregular,  and  shortened,  which 
is  accelerated  by  friction  due  to  muscular  spasm. 

Joint  Abscess.— The  perforation  of  the  joint  is  followed  by  what  may 
be  termed  a  "joint  abscess."     The  clear,   yellowish,  fibrinous  character  of 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


75 


the  fluid  of  the  joint  which  is  present  before  perforation  takes  place  is  soon 
changed  to  a  turbid  character  due  to  the  presence  of  polymorphonuclear  leu- 
kocytes, and  later  the  entire  joint  is  filled  with  an  opaque  fluid  in  which  are 
masses  of  fibrin,  necrotic  portions  of  soft,  articular,  and  bony  structures,  and 
in  which  normal  joint  structures  are  indistinguishable.  When  the  destruc- 
tive changes  have  progressed  to  a  certain  stage,  there  occurs  perforation  of 
the  capsule  of  the  joint  and  the  formation  of  a  secondary  abscess.  This 
generally  occurs  when  the  surrounding  extra-articular  structures  are  the  seat 
of  edematous  infiltration  and  various  secondary  changes.  As  a  rule,  this  is 
mostly  marked  by  the  formation  of  connective  tissue  about  the  muscles  and 
tendons,  so  that  the  parts  finally  consist  of  -  -  ~ 

an  indefinite  mass,  the  characteristics  of 
which  are  found  in  the  peri-articular  swell- 
ing which  occurs  about  all  chronic  joints. 
As  secondary  abscesses  develop  they  gener- 
ally follow  the  lines  of  least  resistance,  pro- 
duce secondary  changes  in  the  surrounding 
soft  parts,  rapidly  form  large  abscess  cavities, 
and  finally  reach  the  surface  at  some  distant 
point,  where  they  perforate  the  skin  in  several 
places,  with  the  formation  of  tuberculous 
fistulas. 

There  is  a  tuberculous  joint  lesion,  most 
frequently  seen  in  the  shoulder,  in  which  the 
amount  of  fluid  is  small  and  abscess  forma- 
tion very  slight.  This  condition  is  known  as 
"caries  sicca."  There  is  a  formation  of  thin,  slightly  vascular,  granulation 
tissue,  which  gradually  destroys  the  head  of  the  bone,  and  in  advanced  cases 
the  disease  may  involve  the  shaft  of  the  bone. 

Spina  Ventosa.— Tuberculous  disease  of  the  phalanges  of  the  hand  and 
foot  is  occasionally  seen  as  an  example  of  tuberculous  infection  of  the  di- 
aphysis.  It  is  sometimes  termed  "spina  ventosa."  The  process  consists  of 
a  tuberculous  process  attacking  the  marrow,  while  at  the  same  time  there 
occur  successive  layers  of  new  cortical  bone  formed  by  the  periosteum.  As 
the  condition  progresses  the  central  portion  of  the  shaft  of  the  bone  is  finaUy 
converted  into  caseous  tuberculous  matter,  containing  numerous  portions  of 
bone   trabecule.     Occasionally   large   sequestra   are   formed.     As   each   new 


Fig.  65. — Separation  of  Articular  Car- 
tilage (Nichols). 
a,   Elevated  cartilage;   b,  head  of  femur. 
Surface  tubercles. 


76  ORTHOPEDIC  SURGERY. 

layer  of  periosteal  bone  is  formed,  the  bone  increases  in  circumference  and 
finally  becomes  spindle-shaped.  At  times  the  tuberculous  process  is  so  rapid 
that  there  remains  only  the  periosteum  as  a  very  thin  shell.  The  tubercu- 
lous area  generally  discharges  externally  in  several  places.  The  disease  is 
usually  seen  in  children,  is  sometimes  found  simultaneously  in  several  pha- 
langes or  metacarpals  at  the  same  time,  but  rarely  are  two  adjacent  bones 
involved.  The  cartilaginous  ends  of  the  bones  are  not  affected  and  the  con- 
dition is  met  vsrith  at  times  in  children  who  have  other  tuberculous  bone  or 
joint  lesions. 

Atypical  Tuberculous  Joint  Lesions. 

Secondary  Tuberculous  Synovitis. — ^Whether  tuberculous  infection  of 
the  synovial  membrane  occurs  as  a  primary  condition  is  not  definitely  settled. 
Many  writers,  especially  the  Germans,  claim  that  primary  tuberculous  syn- 
ovitis is  seen  in  about  20  to  35  per  cent,  of  cases.  Volkmann,  Krause,  Konig, 
and  Watson  Cheyne  consider  that  primary  infection  of  the  synovial  mem- 
brane occurs,  that  it  is  more  often  seen  in  children,  and  most  commonly  at 
the  knee-joint.  Nichols,  on  the  other  hand,  doubts  very  much  the  existence 
of  primary  tuberculous  synovitis,  and  bases  his  statements  on  the  most  care- 
ful examination  of  120  tuberculous  joints  from  children  and  adults. 

The  work  of  Nichols  has  been  so  thorough  and  complete,  and  is  based 
entirely  upon  the  examination  of  pathologic  specimens,  that  one  is  led  to 
believe  that  the  situation  of  the  disease  without  any  doubt  primarily  takes 
place  in  the  epiphyseal  ends  of  the  bone,  and  that  the  sjmovial  membrane 
is  always  secondarily  involved.  His  researches  clear  up  to  a  marked  extent 
cases  that  for  a  long  time  show  nothing  but  a  simple  chronic  synovitis  plus 
moderate  peri-articular  induration.  This  condition,  while  it  may  exist  for 
a  long  period,  is  always  preliminary  to  the  perforation  of  the  joint,  which 
takes  place  sooner  or  later.  This  class  of  cases,  while  showing  clinically 
nothing  more  than  a  chronic  synovitis,  with  the  exception  of  a  little  muscu- 
lar spasm,  slight  limitation  of  motion,  and  moderate  peri-articular  induration, 
may  continue  in  this  stage  for  a  considerable  period,  when,  owing  to  loss  of 
local  resistance,  the  tuberculous  process  becomes  active  and  all  the  signs  of 
a  tuberculous  joint  lesion  develop.  The  chronicity  of  the  condition  is  ex- 
plained on  the  supposition  that  repeated  successful  efforts  have  been  made 
by  nature  to  inclose  the  diseased  focus,  and  the  joint  changes  are  due  to  a 
S}Tnpathetic  inflammation. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  79 

Caries  Sicca. — This  form  of  tuberculous  joint  disease  is  characterized 
by  the  formation  of  thin,  poorly  nourished  granulation  tissue  which  rapidly 
involves  the  epiphysis  and  destroys  the  bone  without  the  formation  of  fluid 
or  any  marked  caseation.  This  condition  is  usually  seen  in  tuberculous  dis- 
ease of  the  shoulder-joint.  The  process  begins  by  the  formation  of  deep 
furrows  and  sinuses  at  the  anatomic  neck,  the  head  of  the  bone  is  rapidly 
destroyed,  and  in  many  instances  the  shaft  of  the  bone  is  involved.  There 
is  little  tendency  to  the  formation  of  sequestra.  Coincident  with  the  destruc- 
tion of  the  head  of  the  bone  shrinkage  of  the  capsule  takes  place,  so  that  the 
upper  end  of  the  shaft  is  drawn  upward  toward  the  glenoid  cavity,  and  this, 
combined  with  the  effect  of  muscular  spasm,  produces  marked  deformity. 

Rice  Bodies. — While  "rice  bodies"  are  usually  seen  in  tuberculous 
lesions  of  the  tendon-sheaths  and  bursas,  they  are  occasionally  met  in  similar 
afliections  of  joints.  These  bodies  are  of  irregular  size,  generally  about  the 
size  of  pieces  of  rice  to  melon-seeds,  grayish-white,  smooth,  numerous,  and 
may  assume  various  shapes  dependent  upon  their  number  and  their  situa- 
tion. Occurring  in  joints,  they  are  formed  from  vUlous  projections  from 
the  hypertrophied  synovial  membrane.  They  may  be  free  or  pedunculated, 
and  are  generally  surrounded  by  a  slightly  turbid  fluid.  When  involving 
bursas  and  tendon-sheaths,  they  present  marked-  enlargements  of  the  bursas 
and  tendon-sheaths,  and  in  the  former  condition  are  sometimes  confounded 
with  sarcoma,  especially  when  the  subdeltoid  bursa  is  affected.  The  con- 
dition may  advance  to  the  formation  of  cold  abscesses. 

Mixed  Infection  of  Tuberculous  Joint  Lesions. — While  the  great 
majority  of  tuberculous  joints  and  abscesses,  when  not  communicating  with 
the  exterior,  remain  uninfected  with  other  pyogenic  organisms,  yet  occasion- 
ally closed  lesions,  and  generally  all  open  areas  of  tuberculous  suppuration, 
sooner  or  later  become  infected  with  other  pyogenic  organisms,  and  the  con- 
dition is  termed  "mixed  infection."  The  most  frequent  organisms  causing 
secondary  or  "mixed  infection"  are  the  streptococcus,  staphylococcus,  the 
pyogenes  aureus  and  citreus,  and  colon  bacillus.  When  this  infection  takes 
place  in  closed  lesions,  the  condition  known  as  "cold  abscess"  is  changed. 
Local  signs  of  an  acute  inflammatory  process  rapidly  become  manifest.  When 
the  cold  abscess  has  been  incised  or  has  ruptured  and  infection  takes  place, 
the  discharge  rapidly  increases  in  quantity  and  quality,  local  signs  of  acute 
inflammation  develop,  and  the  lining  wall  of  the  abscess  is  rapidly  changed. 
If  drainage  is  free,  some  systemic  signs  of  the  infection  will  appear  for  a  few 


80 


ORTHOPEDIC  SURGERY 


days,  but  will  rapidly  subside,  and  in  most  cases  the  local  tuberculous  pro- 
cess may  be  benefited  by  the  increased  blood  brought  to  the  part  and  by  the 
antagonistic  action  of  the  toxins  produced  by  the  pyogenic  organisms  caus- 
ing the  tubercle  bacilli  to  lose  their  virulence.  If,  however,  drainage  is  not 
free  and  the  discharge  has  but  a  small  chance  to  escape,  the  joint  is  rapidly 
destroyed,  abscesses  form  between  the  various  layers  of  muscles,  and  con- 
stitutional effects  of  the  mixed  infection  soon  become  manifest.  As  a  result 
general  resistance  is  lowered,  tuberculous  dissemination  is  favored,  and  amy- 
loid degeneration  of  the  internal  viscera  rapidly 
occurs.  If  the  condition  progresses,  the  only 
hope  of  saving  the  patient's '  life  vdU  depend 
upon  thorough  removal  of  the  part  by  ampu- 
tation. 

Repair  of  Tuberculous  Lesions. — Dur- 
ing the  entire  active  stage  of  tuberculous  lesions 
nature  makes  efforts  at  repair.  For  a  time  the 
local  condition  may  be  so  poor  that  efforts  at 
resistance  are  futile  and  the  surrounding  waU 
of  granulation  tissue  soon  becomes  invaded  by 
the  tubercle  bacilli.  The  process  of  repair, 
however,  may  occur  at  any  stage  of  the  disease. 
Small  areas  of  disease  are  absorbed,  and  re- 
placed by  scar  tissue.  The  main  factor  at  work 
in  the  process  of  repair  is  the  formation  of  sur- 
rounding granulation  and  fibrous  tissue.  Cavi- 
ties are  filled  and  replaced  by  fibrous  tissue, 
sequestra  and  caseous  material  are  encapsul- 
ated by  granulations  which  later  are  converted 
Joint  cavities  are  generally  obliterated  and  the 
articular  surfaces  united  by  fibrous,  cartilaginous,  or  bony  ankylosis,  or 
by  a  combination  of  the  three.  Ankylosis  may  take  place  in  any  position 
dependent  upon  the  presence  or  absence  of  deformity  maintained  during  the 
active  stages  of  the  disease.  Complete  healing  does  not  always  take  place 
imtU  some  little  time  has  passed.  There  generally  persist  small  areas  that 
are  lightly  encapsulated  and  sinuses  which  lead  down  to  a  sequestrum.  These 
semi-active  foci  are  liable  at  times  to  start  afresh  the  previous  tuberculous 
lesions.  This  is  especially  so  when  efforts  are  made  too  early  to  correct 
deformities  in  the  endeavor  to  secure  a  fairly  movable  joint. 


Fig.  67. — Vertebral  Caries,  show- 
ing Ankylosis  from  Exostoses 
(Wistar  Institute  of  Anatomy). 


into  fibrous   calcified   tissue. 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY. 


81 


In  recovery  from  tuberculous  joint  lesions  in  children  it  is  necessary  to 
bear  in  mind  the  changes  which  are  liable  to  occur  as  a  result  of  a  partial  or 
complete  destruction  of  the  epiphysis.  As  a 
rule,  the  entire  epiphysis  is  not  destroyed  by 
the  tuberculous  process,  and  there  later  result 
changes  in  the  position  and  perhaps  accentua- 
tion of  the  deformity  as  a  result  of  the  increased 
growth  of  the  part  not  affected  by  the  disease. 
This  is  seen  in  the  production  of  valgus  and 
varus  deformities  and  other  varieties  of  lateral 
and  anteroposterior  deformities.  As  a  result  of 
irritation  of  the  epiphysis  caused  by  the  tubercle 
bacilli  there  is  generally  an  increased  growth  with 
appreciable  lengthening  of  the  limb.  As  a  result 
of  the  enforced  rest  necessitated  by  the  diseased 
process  there  is  a  retardation  in  growth  of  the 
bony  structures  of  the  entire  extremity  affected. 


Diagnosis. 

An  early  diagnosis  of  tuberculous  joint  dis- 
ease is  extremely  valuable,  so  that  the  recogni- 
tion of  the  condition  is  positive,  and  early  treat- 
ment, upon  which  to  a  great  measure  depend 
good  results,  instituted.  In  the  later  stages  the 
clinical  picture  cannot  be  mistaken,  but  the  early 
diagnosis  is,  in  many  cases,  extremely  difficult. 
The  clinical  picture  presented  in  the  primary 
stages  may  give  some  suggestion  as  to  the  con- 
dition. Among  these  may  be  mentioned  tend- 
ency to  joint  weakness,  early  exhaustion,  slight 
muscular  spasm,  muscular  atrophy  above  and 
below  the  joint,  localized  tenderness  over  the 
epiphysis,  slight  effusion,  and  peri-articular 
edema.  As  an  aid  to  clinical  signs  the 
tuberculin  reaction  has  been  extensively  used. 


Fig.  68. — Tuberculous  Hip-joint 
Disease  (Wistar  Institute  of 
Anatomy). 


It  is  of  value  as  a  negative 
test  showing  the  absence  of  tuberculous  lesions  in  the  body,  but  its  use- 
fulness as  a  positive  test  is  practically  nil,  when  we    consider   the  fact    that 


82  ORTHOPEDIC  SURGERY. 

joint  lesions  are  usually  secondary  to  a  tuberculous  condition  of  the  lymph- 
atic glands.  The  .T-ray  photograph  is  of  little  value  in  the  early  diagnosis 
of  tuberculous  lesions,  as  it  fails  to  reveal  foci  until  they  are  of  large  size. 
It  may  be  of  use  in  showing  changes  in  the  head  and  neck  of  the  femur  in 
early  disease,  on  account  of  the  static  changes  which  occur.  Positive  early 
diagnosis  is  difficult,  but  if  the  disease  has  invaded  the  synovial  membrane, 
arthrotomy,  and  inspection  of  the  membrane  and  the  excision  of  a  small  por- 
tion, followed  by  histologic  examination  and  inoculation  into  susceptible  ani- 
mals, offer  the  only  means  by  which  the  condition  can  be  absolutely  deter- 
mined.    The  author  does  not  recommend  this  latter  method  of  diagnosis. 

Prognosis. 

The  prognosis  in  tuberculous  joint  disease  is  dependent  upon  a  num- 
ber of  conditions.  The  patient's  general  surroundings  greatly  influence  the 
prognosis.  Anything  which  lessens  the  general  as  well  as  the  local  resistance 
tends  to  favor  the  growth  and  dissemination  of  tuberculosis.  These  include 
lack  of  proper  food,  air,  and  exercise.  Age  affects  the  prognosis  of  tubercu- 
lous joint  diseases.  This  is  in  part  due  to  the  increased  frequency  of  the 
presence  of  phthisis  among  adults  even  before  the  development  of  the  joint 
lesions,  and  in  part  due  to  the  natural  retrograde  changes  which  take  place 
with  increasing  years.  This  influence  of  age  upon  the  death-rate  is  shown 
by  the  following  statistics  of  Konig  on  tuberculous  disease  of  the  knee-joint: 

Less  than  fifteen  years  of  age, 20  per  cent. 

From  sixteen  to  thirty  years, 24 

From  thirty  to  forty  years, 44 

More  than  forty  years, 60 

The  prognosis  is  dependent  upon  the  situation,  its  accessibility,  its  proxim- 
ity to  surrounding  structures,  and  the  degree  with  which  it  can  be  treated 
without  subjecting  the  patient  to  undue  pain  or  confinement.  Dependent 
upon  situation  and  proximity  to  important  structures,  it  may  be  stated  that 
the  danger  to  life  is  much  greater  in  disease  of  the  vertebras  than  when  the 
lesion  involves  joints  of  the  extremities.  Pressure  upon  the  spinal  cord  is 
liable  to  occur,  and  the  danger  from  this  source  is  greater  in  tuberculous  dis- 
ease of  the  cervical  than  of  the  dorsal  or  lumbar  vertebras.  Disease  of  the 
cervical  vertebras  is  more  difficult  to  treat  than  similar  lesions  of  other  joints. 
Abscess  formation  is  more  dangerous  in  vertebral  disease:  on  account  of 
their  size  and  proximity  to  important  structures  there  is  danger  of  compres- 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  83 

sion  and  rupture  into  important  viscera,  and  of  thereby  setting  up  secondary- 
lesions.  The  prognosis  is  much  better  in  tuberculous  lesions  of  joints  which 
are  readily  accessible  to  prompt  treatment.  This  is  seen  in  the  more  grave 
prognosis  in  hip-joint  disease  than  in  other  joints.  In  disease  of  the  knee- 
joint  the  parts  are  so  superficial  that  the  condition  is  readily  recognized,  and 
if  operative  measures  are  instituted,  the  parts  are  very  accessible.  Joints  that 
can  efficiently  be  treated  without  confining  the  patient  or  without  causing 
much  pain  yield  more  readily  to  treatment,  and,  all  things  considered,  the 
danger  to  life  is  not  so  great.  Abscess  formation  materially  increases  the 
gravity  of  the  prognosis.  Konig's  and  Bruns's  statistics  showing  that  the 
mortality  is  increased  very  markedly  when  abscesses  occur  are  as  follows: 


Joint  Affected. 

Without  Abscess. 

With  Abscess. 

Konig,  . . . 

Knee-joint. 

25  per  cent. 

46  per  cent. 

Bruns, 

Hip- joint. 

23 

52'       " 

When  abscess  formation  takes  place,  one  of  the  causes  that  materially  increase 
the  mortality  rate  is  "mixed  infection"  with  pyogenic  organisms.  While 
this  may  be  slight  in  joints  which  are  superficially  located,  are  not  in  prox- 
imity to  important  structures,  and  where  efficient  drainage  is  present,  in 
cases  in  which  these  conditions  are  not  present  the  effects  of  systemic  infec- 
tion are  seen  very  early,  the  general  condition  rapidly  faUs,  amyloid  degen- 
eration of  the  internal  viscera  takes  place,  and  the  patient  succumbs  to  the 
combined  effects  of  the  disease. 

The  statistics  on  the  effect  operation  has  upon  the  spread  of  tuberculous 
disease  are  few  and  conflicting.  As  a  general  rule,  however,  it  may  be  stated 
that  the  statistics  show  that  the  death-rate  has  not  been  increased  by  opera- 
tive intervention. 

The  statistics  on  the  cause  of  death  are  numerous.  BUlroth  and  Men- 
zel  collected  2106  cases  of  tuberculous  disease  of  the  bones  and  joints  from 
the  autopsy  records  at  Vienna,  and  stated  that  52  per  cent,  showed  tuber- 
culosis of  the  internal  organs.  Warthman  states  that  in  837  cases  of  resec- 
tion of  the  hip  10  per  cent,  of  the  patients  died  of  general  tuberculosis; 
which  he  does  not  consider  to  have  been  brought  on  by  the  operations.  In 
386  cases  of  tuberculous  joint  disease  kept  under  observation  for  three  years 
Watson  Cheyne  states  that  10.8  per  cent,  had  contracted  or  died  of  phthisis 
or  tuberculous  meningitis.  Jaffe  states  that  53  per  cent,  of  deaths  are  due 
to  general  tuberculous  infection;  Billroth  states  that  54  per  cent,  die  of  acute 
miliary  tuberculosis.     Whitman  states  that  among  the  cases  of  tuberculosis 


84  ORTHOPEDIC  SURGERY. 

of  the  bones  and  joints  treated  at  the  New  York  Orthopedic  Dispensary  and 
Hospital  during  a  period  of  twenty  years  at  least  25  per  cent,  died  of 
tuberculous  meningitis.  The  mortality  statistics  of  cases  in  which  the  tuber- 
culous bone  foci  were  removed  are  interesting  in  showing  that  the  death- 
rate  is  practically  unaffected  and  that  the  dissemination  of  the  disease  takes 
place  generally  from  the  primary  focus.  Konig  reports  that  of  117  resec- 
tions performed  for  tuberculous  joint  disease  there  were  25  deaths,  18  being 
due  to  general  tuberculosis,  and  that  9  more  cases  had  tuberculosis  in  an 
advanced  stage.  Caumont's  statistics  show  that  in  26  cases  of  tuberculous 
hip  disease,  in  which  no  operations  were  performed  about  one-fifth  died  of 
generalized  tuberculosis,  whUe  in  12  other  cases  in  which  resection  was  per- 
formed one-third  died  from  the  same  cause.  Gibney  considers  deaths  from 
generalized  tuberculosis,  in  cases  having  tuberculous  joint  lesions,  to  be  no 
greater  in  those  cases  in  which  surgical  interference  is  instituted.  He  bases 
his  statements  on  an  observation  of  the  results  obtained  during  two  equal 
periods  of  thirteen  years  at  the  Hospital  for  Ruptured  and  Crippled;  dur- 
ing the  first  period  the  cases  were  treated  by  conservative  means.  From 
the  above  statistics  it  may  be  inferred  that  operative  intervention  has  practic- 
ally no  influence  upon  the  dissemination  of  tuberculosis  from  the  primary 
foci,  but  it  cannot  be  doubted  that  some  benefit  must  follow  in  the  improved 
general  condition  by  the  removal    of  a  suppurating  focus  of  disease. 

Treatment. 

It  is  needless  to  state  that  the  general  hygienic  t,urroundings  should  re- 
ceive the  most  careful  attention.  The  food  should  be  easily  digestible  and 
very  nourishing.  Patients  should  spend  as  much  time  as  possible  in  the  open 
air.  This  has  been  made  possible  in  late  years  by  the  various  methods  of 
ambulatory  treatment  which  have  almost  entirely  supplanted  the  older 
methods  which  necessitated  spending  long  periods  in  bed.  This  has 
changed  to  such  a  degree  that  but  few  cases  now  require  recumbent  treat- 
ment. General  tonics,  such  as  hypophosphites,  cod-liver  oU,  and  prepara- 
tions containing  iron,  arsenic,  and  strychnin,  may  be  used  to  advantage;  but 
their  continued  use  over  long  periods  is  not  advised  on  account  of  the  destruc- 
tive action  many  such  preparations  have  on  the  teeth,  the  decay  of  which 
does  not  tend  to  increase  the  patient's  general  health. 

Conservative  Treatment.— The  results  obtained  by  conservative  treat- 
ment in  tuberculous  joint  disease  have  during  the  past  few  years  been  so 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  85 

good  that  many  orthopedic  surgeons  consider  that  operative  intervention  is 
generally,  if  not  always,  inadvisable.  The  good  results  obtained  by  con- 
servative treatment  are  due  to  the  improved  methods  of  fixation  and  exten- 
sion, which  permit  of  ambulatory  treatment,  and  the  great  strides  that  have 
been  made  in  the  improvement  of  orthopedic  apparatus.  Contrasting  non- 
operative  with  operative  treatment,  it  will  be  found  that  the  prognosis  under 
the  two  methods  of  treatment  varies  but  little.  The  essential  features  of 
conservative  treatment  are  absolute  fixation  and  extension  permitting  of  am- 
bulatory treatment  and  the  spending  of  as  much  time  as  possible  in  the  open 
air.  Fixation  and  traction  may  be  obtained  in  most  tuberculous  joint  lesions 
by  means  of  suitable  orthopedic  braces  and  splints  of  various  materials. 
As  soon  as  the  diagnosis  is  made,  treatment  should  be  immediately  instituted. 
If  seen  early,  suitable  ambulatory  apparatus  or  splints  should  be  applied. 
If  the  disease  is  well  advanced  and  muscular  spasm  and  deformity  are  pres- 
ent, it  may  be  necessary  to  overcome  both  by  the  recumbent  position  in  bed 
and  traction.  The  continuous  use  of  plaster-of-Paris  dressings  applied  every 
week  without  any  attempt  being  made  to  correct  the  position  will  soon  over- 
come the  deformity  and  lessen  the  muscular  spasm.  After  the  latter  condi- 
tions have  been  overcome  suitable  ambulatory  apparatus  should  be  used. 

Local  Measures.  Iodoform  Emulsion. — Local  measures  may  be  used 
to  good  effect  as  supplementary  to  conservative  measures.  Among  these 
may  be  mentioned  iodoform.  The  results  obtained  by  the  injection  of  iodo- 
form into  joints  are  often  striking,  and  although  its  favorable  influence  is  not 
constant,  yet  many  cases  of  joint  disease  are  greatly  improved  and  the  joint 
effusion  may  disappear  rapidly  and  permanently.  The  action  of  iodoform 
is  supposed  to  promote  the  growth  of  well-nourished  granulation  tissue 
which  to  a  certain  extent  destroys  the  tubercle  bacilli  and  later  forms  fibrous 
tissue.  The  germicidal  action  of  iodoform  is  doubted  very  much.  At  one 
time  iodoform  was  iajected  into  the  bone  near  the  osseous  focus,  but  lately 
this  treatment  is  no  longer  used,  and  the  only  cases  in  which  the  injections 
are  used  are  those  of  synovitis,  bursitis,  tenosynovitis,  and  abscesses.  The 
iodoform  is  used  in  the  form  of  a  lo  per  cent,  emulsion  made  of  sterile  gly- 
cerin or  oil.  General  anesthesia  is  not  necessary.  The  technic  of  injecting 
consists  in  aspirating  the  affected  joint  at  the  most  convenient  position 
under  strictest  aseptic  precautions.  The  fluid  within  the  joint  is  removed 
and  5  to  lo  c.c.  of  the  iodoform  emulsion  is  injected.  The  wound  should 
be  sealed  with  a  sterile  dressing.      The  injection  is  repeated  every  ten  to 


86  ORTHOPEDIC  SURGERY. 

fourteen  days.  At  the  end  of  twenty-four  hours  there  are  generally  signs 
of  marked  irritation  about  the  joint,  moderate  fever,  an  increase  in  the  effu- 
sion, and  pain.  All  these  symptoms,  however,  rapidly  subside.  The  results 
of  the  first  injections  are  carefully  noted  and  the  tolerance  of  the  individual 
established.  Good  effects  are  shown  by  the  moderation  of  the  process  and 
signs  of  cicatrization  and  healing  within  the  joint.  In  cases  in  which  abscess 
formation  has  occurred,  its  favorable  action  is  shown  by  a  greenish  character 
of  the  pus  and  by  the  tendency  of  the  fluid  to  become  serous.  While  injec- 
tions of  iodoform  have  in  some  instances  been  followed  by  fatal  cases  of 
poisoning,  yet  under  careful  treatment  and  noting  the  local  and  general  action 
of  the  iodoform  one  can  usually  see  the  signs  of  danger  and  the  personal 
tolerance. 

Carbolic  Acid. — The  injection  of  dilute  solutions  of  carbolic  acid  in- 
stead of  iodoform  emulsion  in  the  treatment  of  tuberculous  joint  disease  has 
been  advocated  by  some  authors.  Konig  recommends  that  the  joint  be  as- 
pirated and  all  effusion  withdrawn;  then  irrigated  with  a  2  per  cent,  car- 
bolic acid  solution,  after  which  a  5  per  cent,  solution  of  the  same  is  allowed 
to  remain  in  the  joint.  The  after-results  and  further  technic  are  similar  to 
injections  of  iodoform.  Konig  claims  to  have  good  results  from  this  form 
of  treatment.  In  the  use  of  weak  solutions  of  carbolic  acid  there  is  always 
the  danger  of  poisoning  from  absorption,  and  on  this  account  it  is  very  little 
used.  The  use  of  pure  carbolic  acid  in  the  treatment  of  tuberculous  abscess 
cavities,  sinuses,  and  skin  tuberculosis  has  been  followed  by  good  results. 
It  differs  from  dilute  solutions  in  that  it  is  not  absorbed,  but  has  an  entirely 
local  escharotic  action,  while  the  latter  is  absorbed.  In  using  the  pure  car- 
bolic acid  the  walls  of  the  cavity,  if  accessible,  should  be  swabbed  and  the 
acid  neutralized  by  95  per  cent,  alcohol,  which  should  be  followed  by  irri- 
gation with  normal  salt  solution.  Other  agents  used  which  depend  entirely 
on  their  local  escharotic  action  are  chromic  acid,  chlorid  of  iron,  nitric  acid, 
tincture  of  iodin,,  and  the  Paquelin  cautery.  By  their  local  action  these 
agents  destroy  the  tubercle  bacUli  in  the  lining  walls  of  the  abscess,  hasten 
the  separation  of  the  infected  granulations,  and  promote  the  formation  of 
more  healthy  granulation  tissue. 

Externally  in  the  early  stages  of  tuberculous  joint  disease  counterirri- 
tants,  like  tincture  of  iodin,  cantharides,  and  the  Paquelin  cautery,  may  help 
in  promoting  the  absorption  of  the  effusion  within  the  joint. 

If  tuberculous  skin  lesions  develop  from  extension  from  a  tuberculous 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  87 

fistula,  satisfactory  results  may  be  obtained  by  the  local  use  of  iodoform, 
ichthyol,  tincture  of  iodin,  and  balsam  of  Peru.  If  more  powerful  agents  are 
required,  the  escharotics  mentioned  above  may  be  used. 

Passive  Congestion. — The  treatment  of  tuberculous  joint  disease  as 
suggested  by  Rokitanski  and  later  used  extensively  by  Bier  has  been  recom- 
mended by  many  orthopedists.  While  of  limited  use  in  this  country,  it  is 
undoubtedly  of  value  in  certain  selected  cases.  The  method  consists  in  caus- 
ing local  passive  congestion  about  the  diseased  joint.  This  is  produced  by 
constricting  the  limb  above  the  joint  by  means  of  a  rubber  bandage,  placed 
sufficiently  tight  to  arrest  the  venous  but  not  the  arterial  blood-current.  A 
flannel  bandage  is  then  applied  from  the  distal  end  of  the  extremity  to 
belovir  the  affected  joint.  The  joint  region  becomes  cyanotic,  edematous, 
and  local  temperature  is  increased.  No  pain  should  be  produced.  The 
daily  treatment  should  last  from  twelve  to  fourteen  hours.  Bier  claims 
that  the  effects  produced  by  passive  congestion  are:  (i)  It  hastens  the 
formation  of  fibrous  tissue  and  causes  hypertrophy  of  the  bones;  (2)  it 
assists  in  absorption  of  the  effusion  and  such  new-formed  tissue  as  is  liable 
to  prevent  joint  motion;  (3)  pain  is  lessened  and  joint  motion  is  much  freer; 
and  (4)  it  has  a  bactericidal  effect  in  infectious  joint  diseases,  particularly 
tuberculosis.  At  present  there  is  little  to  show  that  passive  congestion  has 
any  real  curative  power  in  early  tuberculous  joint  disease.  That  it  relieves 
pain  and  facilitates  freer  joint  motion  is  well  understood.  Many  cases  are 
not  at  all  benefited.  The  formation  of  abscesses  takes  place  more  rapidly 
under  this  form  of  treatment.  Bier  considers  this  as  a  favorable  sign.  They 
may  be  aspirated  and  injected  with  iodoform  emulsion.  Large  abscesses 
should  contraindicate  its  use.  At  present  statistics  on  the  subject  are  meager. 
Some  authorities  report  very  favorably,  others  have  had  poor  results.  No 
doubt  as  more  cases  are  observed  under  this  form  of  treatment  a  selection 
of  suitable  cases  will  be  possible,  so  that  in  time  the  indications  for  its  use 
wUl  be  more  exact.  The  method  when  used  should  be  closely  observed  in 
all  cases. 

Radiotherapy. — The  good  results  obtained  in  the  treatment  of  tuber- 
culous skin  lesions  by  the  x-xasy  have  led  to  its  use  in  tuberculous  joint  affec- 
tions. While  it  is  impossible  to  say  whether  its  use  is  followed  by  good  results 
in  the  intra-articular  affections,  there  can  be  no  doubt  that  in  cases  in 
which  there  are  discharging  sinuses  with  extension  of  the  process  to  the  sur- 
rounding skin  much  benefit  attends  its  application.     No   statistics    on    this 


88  ORTHOPEDIC  SURGERY. 

form  of  treatment  have  so  far  appeared,  yet  in  suitable  cases  it  may  be 
used. 

Final  Results  Obtained  under  Conservative  Treatment.— Tiie  aver- 
age period  of  conservative  treatment  is  from  two  to  five  years.  Statistics 
show  that  under  this  form  of  treatment  muscular  atrophy  is  less,  there  is 
generally  less  shortening,  there  is  a  smaller  percentage  of  abscess  formation, 
there  may  be  more  cases  of  contraction,  the  period  of  treatment  may  be  pro- 
longed, but  there  is  never  any  danger  of  a  flail  joint  resulting.  If  cases  when 
first  observed  are  far  advanced,  operative  treatment  may  be  necessary  not 
only  to  combat  the  active  tuberculous  lesion,  but  to  overcome  any  deformity 
that  may  be  present.  If  contractures  and  ankylosis  occur,  they  may  require 
tenotomy  or  osteotomy,  which,  however,  should  not  be  performed  until  all 
signs  of  active  disease  have  long  since  disappeared. 

Operative  Treatment. — ^With  the  advent  of  improved  orthopedic  ap- 
paratus and  the  advancement  made  in  conservative  treatment,  fewer  cases 
now  require  operative  interference.  Minor  operations  are  often  necessary 
in  the  treatment  of  abscesses,  fistulas,  and  extra-articular  foci,  which  are  ren- 
dered more  safe  since  the  advent  of  improved  antiseptic  and  aseptic  methods. 
Of  the  various  operations  in  use,  may  be  mentioned  curetage,  excision  of 
osseous  foci  (extra-articular),  arthrectomy,  excision,  and  amputation. 

Curetage. — After  repeated  aspiration  and  injection  with  iodoform  emul- 
sion have  faUed  in  the  treatment  of  cold  abscesses,  or  there  is  danger  of  rup- 
ture or  signs  of  a  mixed  infection  taking  place,  the  abscess  should  be  incised, 
the  walls  of  the  cavity  removed  by  a  blunt  curet,  and  the  cavity  packed  with 
iodoform  gauze.  Persistent  sinuses  may  be  closed  by  the  removal  of  the  in- 
dolent granulations  and  fibrous  tissue  lining  the  cavity  by  means  of  curetage. 

Excision  of  Osseous  Foci. — There  has  been  a  tendency  of  late  to  op- 
erate, in  tuberculous  diseases  of  the  joints,  as  soon  as  the  diagnosis  is  made 
and  the  position  of  the  osseous  focus  definitely  located.  While  the  3f-ray 
photograph  does  not  show  the  presence  of  an  osseous  focus  until  it  has 
reached  a  considerable  size,  yet  certain  static  changes  may  take  place  in  the 
neighboring  bone,  as  is  sometimes  seen  in  the  neck  of  the  femur  when  osseous 
foci  are  present,  which,  combined  with  the  clinical  signs,  may  lead  to  defin- 
ite localization.  By  early  operation  the  focus  may  be  thoroughly  removed 
with  the  gouge,  curet,  and  chisel.  If  the  disease  is  extra-articular,  early  cure 
should  result.  The  more  frequently  operations  are  thus  performed,  the  greater 
chance  there  will  be  that  the  joint  has  not  become  involved,  and  the  period 


GENERAL  ETIOLOGY  AND  PATHOLOGY  OF  DEFORMITY.  89 

of  convalescence  will  be  materially  shortened.  If  the  joint  has  become  in- 
fected, no  further  harm  can  be  done  by  early  exploratory  operation.  Ab- 
scesses form  in  a  large  number  of  cases  that  are  treated  by  conservative 
means.  This  would  be  avoided  by  early  operation,  and  if  they  were  already 
present,  there  can  be  no  doubt  that  the  termination  of  the  active  stage  of  the 
disease  would  be  materially  hastened  by  measures  that  could  be  used  at  the 
time  of  the  exploratory  operation. 

Arthrectomy  or  Erasion. — Arthrectomy  is  an  operation  of  election 
during  the  early  stage  of  the  disease  after  the  joint  has  become  involved.  By 
this  operation  attempts  are  made  to  remove  all  diseased  structures,  particu- 
larly the  entire  synovial  membrane  and  the  area  of  bone  surrounding  the 
osseous  focus.  All  healthy  portions  are  left  intact.  The  aim  of  the  opera- 
tion is  to  retain  good  structures,  to  hasten  recovery,  and  to  avoid  if  possible 
the  deformity,  shortening,  and  partial  loss  of  function  which  follow  all  ex- 
cisions. The  operation  is  to  a  certain  extent  successful,  as  it  undoubtedly 
hastens  recovery  and  prevents  the  shortening,  probable  ankylosis,  and  pos- 
sible flail  joint  incident  to  excision.  Very  often,  however,  ankylosis  and 
certain  contractures  occur  ^Yhich  later  may  require  excision.  The  mortality 
of  arthectomy  is  not  so  great  as  excision.  In  children  arthrectomy  should 
be  performed  rather  than  excision  on  account  of  not  interfering  with  the  epi- 
physes. 

Excision. — The  operation  of  excision  is  the  one  of  choice  in  adults  when 
it  is  desirable  to  remove  as  much  as  possible  of  the  tuberculous  disease  without 
amputation,  when  time  is  of  importance,  when  there  is  mixed  infection  of  the 
joint  with  symptoms  of  systemic  infection,  and  when  bony  union  is  desirable. 
Excision  is  also  performed  for  flexion,  contractures,  and  all  lateral  and  antero- 
posterior deformities  occurring  with  ankylosis.  The  mortality  rate  is  higher 
than  that  of  arthrectomy  and  increases  with  the  age  of  the  individual. 

Amputation. — Amputation  is  indicated  in  old  persons  with  whom  the 
period  of  convalescence  is  of  paramount  importance,  in  cases  in  which  there  is 
rapidly  progressing  or  extensive  phthisis,  amyloid  degeneration,  mixed  in- 
fection with  signs  of  marked  constitutional  disturbance,  and  in  cases  of  marked 
general  weakness. 


CHAPTER    III. 

GENERAL  CLASSIFICATION   AND   GENERAL   STATISTICS 
OF  DEFORMITY. 

Orthopedic  affections  may  be  looked  at  in  any  one  of  three  ways,  and 
accordingly  a  topographic,  a  pathologic,  or  an  anatomic-pathologic  arrange- 
ment may  be  adopted. 

The  first,  or  topographic  arrangement,  is  the  one  usually  employed  by  system- 
atic writers,  and  the  deformities  are  taken  up  seriatim  as  they  affect  the  differ- 
ent portions  of  the  body:  the  head,  neck,  trvmk,  upper  extremity,  lower 
extremity,  etc. 

The  second,  or  pathologic  arrangement,  offers  certain  advantages,  since 
it  gives  a  clue  to  the  cause  and  nature  of  the  affections.  Thus  we  have  the 
division  into  acquired  deformities  and  congenital  deformities,  and  a  subdivi- 
sion of  the  acquired  deformities  into  three  classes  as  they  arise  from  causes 
directly,  indirectly,  or  both  directly  and  indirectly,  affecting  the  articula- 
tions. 

The  third,  or  anatomic-pathologic  arrangement,  is  the  one  here  presented 
as  being  the  most  scientific  and  satisfactory.  The  subject  is  divided  into  six 
parts,  the  affections  being  classed  as  they  are  deformities  dependent  on:  (I) 
Lesions  of  bone;  (II)  lesions  of  synovial  membrane;  (III)  lesions  of  cerebro- 
spinal system;  (IV)  impaired  nutrition,  or  diathesis;  (V)  embryonic  disease  or 
disturbances  of  development;  (VI)  accident  or  traumatism.  These  six  classes 
are  divided,  and  are  again  subdivided  into  the  individual  affections.  It  is 
not  presented  as  a  perfect  arrangement,  but  it  is  the  one  the  writer  has  found 
most  convenient  in  teaching. 

The  subject  may  best  be  divided  into  two  parts,  (i)  as  to  general  ortho- 
pedics, and  (2)  as  to  special  affections. 


CLASSIFICATION  AND  STATISTICS  OF  DEFORMITY. 


91 


CLASSIFICATION  OF  DISEASES  BELONGING  TO  THE   DEPARTMENT  OF  ORTHOPEDIC 

SURGERY. 


Pott's  disease. 

Sacro-iliac  disease. 

Tubercular  Osteitis    - 

Hip-joint  disease. 
Knee-joint  disease. 

Class  I. 

Ankle-joint  disease. 

Lesions  of  bone. 

Other  major  articulations. 

Infectious  or  malig- 
nant diseases 

Osteomyelitis. 
Typhoid. 
Sarcoma. 
,   Carcinoma. 

Class  II. 
Lesions  of  synovial  membrane. 

Ankylosis. 

f  Acute  serous. 
Synovitis \    Chronic  serous. 

1    Intermittent  joint  hydrops. 

Lateral  curvature. 

Paralyses 

Infantile  spinal  paralysis. 

Infantile  cerebral  paralysis. 

Deformities 

Class  III. 
Lesions  of  cerebrospinal  system. 

Spasms 

Other  paralyses. 
Torticollis. 

Neuromimesis. 

^      ,  .    ,.       ,              f  Neuropathic  affections. 

Trophic  disturbances  <,,.,/,,      , 

'^                              (^  Unilateral  development. 

■ 

Knock-knee. 

Rachitis 

Bow-legs. 

Curvatures  of  diaphyses. 

Class  IV. 

Syphihs 

Tardy  syphilis  of  the  bones. 

Impaired  nutrition,  or  diathesis. 

Osteomalacia. 

Inflammation 

Osteitis  deformans. 
Fragilitas  osseum. 

Class  V. 

Embryonic  disease  or  disturbances 

of  development. 

Congenital 

'  Club-foot. 

Dislocations  of  articulations. 

Perverted  development. 
'   Tendon. 

Dislocation 

Cartilage. 

Class  VI. 

Irreducible. 

Accident  or  traumatism. 

Fracture  

Rupture 

Ununited. 
(  Muscular  tissue. 
(   Tendons. 

GENERAL  STATISTICS  OF  DEFORMITY. 

The  great  frequency  of  deformity  is  not  generally  appreciated  by  the  laity 
or  the  profession,  since  many  distortions  are  skilfully  concealed  by  the  suf- 
ferers. 

The  statement  of  Schrauth  that  there  were  25,000  deformed  in  Bavaria, 
and  the  estimate  by  Werner  that  there  were,  in  i860,  56,000  cases  of  scoliosis  in 
Prussia,  has  recently  been  emphasized  by  the  statement  of  Hoffa,  computed 
from  the  government  statistics  of  Germany,  that  there  were  500,000  deformed 


92  ORTHOPEDIC  SURGERY. 

persons  in  the  empire.  The  census  of  England  and  Wales  classes  409)207 
persons  as  deformed,  of  which  number  90,277  were  in  London.  It  has  been  es- 
timated that  there  are  in  the  United  States  alone  30,000  persons  who  spend  from 
twenty  to  forty  years  of  their  lives  in  rolling  chairs. 

In  order  that  statistics  may  be  of  any  value  to  the  surgeon  there  must  be 
a  large  number,  and  they  must  be  arranged  according  to  the  individual 
diseases. 

Statistics  upon  deformity  have  been  collected  in  England  by  Tamplin, 
in  France  by  Duval,  in  Russia  by  Phillips,  and  in  Germany  by  Hoffa,  and 
we  have  these  for  comparison. 

From  the  surgical  clinics  of  Munich,  Hoffa  has  compiled  the  following: 
In  116,978  cases  of  disease  between  1879  and  1889  at  the  Surgical  Polyclinic 
there  were  67,919  surgical  cases,  of  which  1444  were  deformities,  or  2.13  per  cent. 
The  age  at  which  the  deformities  occurred  is  well  shown  in  the  following  table 
from  Hoffa: 

o-io  years, 602  41.68  per  cent.  40-50  years, 54  3.74percent. 

10-20      "     481  32.32       "  50-60      "     30  2.08 

20-30      "     182  12.61       "  60-70      "     28  1.59       " 

30-40      "     70       4.84       "  70-80      "     2  0.14       " 

As  to  the  relative  frequency  of  congenital  and  acquired  deformity,  out 
of  1325  cases  there  were  150  congenital,  11. 3  per  cent.,  and  1175  acquired,  88.7 
per  cent. 

In  compiling  the  individual  aft'ections  Hoft'a  found  the  relative  frequency 
to  be  as  follows: 

Percentage  of 
Cases.  DEFORiirriES. 

Torticollis, 7  0.49  per  cent. 

Scoliosis, 399  27.63  " 

Rachitic  kyphosis,   39  2.07  " 

Tuberculous  kyphosis, 142  9. S3  " 

Club-hand, i  0.07  " 

Dupuytren's  contraction, 23  1.59  " 

Congenital  dislocation  of  the  hip, 7  0.49  " 

Genu  valgum, 119  8.24  " 

Genu  varum, 3  0.21  " 

Rachitic  deformities  of  the  lower  extremities,-.  107  7.41  " 

Pes  calcaneus, 9  0.62  " 

Pes  equinus, 52  3.60  " 

Pes  equinovarus, 171  11. 84  " 

Pes  valgus, 338  23.41  " 

Hallux  valgus, 27  1.87  " 


CLASSIFICATION  AND  STATISTICS  OF  DEFORMITY. 


93 


In  order  to  determine  the  relative  frequency  of  deformity  in  this  city  I 
collected  in  my  first  edition  records  from  the  hospital  of  the  University  of  Pennsyl- 
vania for  ten  years,  from  1884  to  1894,  and  to  these  I  have  added  the  records 
for  the  next  succeeding  ten  years,  making  twenty  years,  from  1884  to  1904. 

From  these  records  I  have  found  that  in  5680  orthopedic  cases  there  ex- 
isted: Pott's  disease,  492;  hip  disease,  506;  knee-joint  disease,  104;  ankle- 
joint  disease,  44;  shoulder-joint  disease,  7 ;  elbow-joint  disease,  20;  wrist-joint 
disease,  10;  lateral  curvature,  293;  knock-knee,  77;  bow-legs,  169;  club-foot, 
318;   and  infantile  paralysis,  162. 

The  importance  of  statistics  upon  the  subject  of  tuberculosis  has  led  me  to 
classify  1000  cases  of  tuberculosis  of  the  bones  and  joints  taken  from  the  records 
of  the  Hospital  of  the  University  of  Pennsylvania  and  of  the  Philadelphia  Poly- 
clinic Hospital.  These  wUl  be  considered  under  the  following  heads:  trau- 
matism, distribution,  side  affected,  sex,  age  of  incipiency,  and  mortality. 

In  298  cases  of  these  1000  cases  the  direct  predisposing  cause  of  the  local 
disease  appeared  to  be  due  to  local  injury. 

The  distribution  of  the  affection  was  as  follows : 


Vertebras, 

Hip-joint, 

Knee-joint, 

Ankle-joint, . . . 
Shoulder-joint, 
Elbow-joint, . . . 
Wrist-joint, 


The  side  affected  was  as  follows: 


Hip, 19s 

Knee-joint, 42 

Ankle-joint, 26 

Shoulder-joint, 

Elbow-joint, 7 

Wrist-joint, 2 

Total, 272 

The  sex  was  as  follows: 

Vertebras, 222 

Hip-joint, 247 

Knee-joint, 65 

Ankle-joint, 16 

Shoulder-joint, 

Elbow-joint, 11 

Wrist-joint, 3 


52.7  per  cent. 
46.1       " 
83-9       " 

53-8       " 
25.0       " 

52.8  " 


243 


416 

41.6  per  cent 

421 

42.1 

103 

10.3       " 

33 

3-3       " 

2 

0.8       " 

17 

1.7       " 

8 

0.2       " 

Left. 

17s 

47.3  per  cent 

49 

53-9       " 

5 

16.1       " 

2 

100. 0       " 

6 

46.2       " 

6 

75-0       " 

47- 


Female. 

54.5  per  cent. 

185 

45.5  per  cent 

58.7       " 

174 

41-3       " 

63.1       " 

38 

36.9       " 

48.S       " 

17 

Si-S       " 

2 

100. 0       " 

64.7       " 

6 

35-3       " 

37-5       " 

5 

62.5       " 

Total, 564 


58.9 


427 


94  ORTHOPEDIC  SURGERY. 

The  age  at  which  application  for  treatment  was  made  was  as  follows: 


0-5. 

5-10. 

10-15, 

15-20, 

20-25, 

25-3°.---- 

30-35 

35-40 

40-45,.... 
45-50.-- -■ 
So-S5.-■-- 
55-60,.... 
60-65,.... 

Total, 


172 
100 

50 
29 

33 
17 
3 
7 
S 
3 


135 
134 
77 
29 

17 
13 
7 


Out  of  the  1000  cases,  the  rate  of  mortality  was  34,  of  which  17  died  under 
conservative  treatment,  and  17  following  operation. 

It  wUl  be  especially  noted  that  the  age  of  incipiency  increases  up  to  the 
seventh  year,  when  there  is  a  decided  fall,  and  again  an  increase. 

From  other  sources  I  have  collected  7243  cases,  which,  together  with  11 83 
cases  previously  collected  by  myself,  make  8426  cases  of  joint  tuberculosis. 
Of  the  7243  cases  collected  from  other  sources,  none  show  the  entire  relative 
proportion,  and  only  two  of  them  are  larger  than  my  o-wm.  Statistics  appear 
to  be  unreliable  chiefly  because  of  extraneous  influences  tending  to  separate 
the  cases.  The  following  table  is  given  to  show  the  variation  which  occurs 
in  Edinburgh,  Vienna,  Philadelphia,  and  other  cities : 


GiBNEV. 

Boston 
Children's 
HosprrAL. 

New  York 
Ortho- 
pedic 

hospitai,, 
1884-S6. 

Albert, 

James, 
Edin- 
burgh, 
1888. 

JUDSON. 

Menzel 

AND 

Billroth. 

Schdlles 

AND 

Socm. 

Young, 
Phila- 
delphia, 
1904. 

Total. 

Hip 

Knee 

Ankle, 

Shoulder,  . . . 

Elbow, 

Wrist, 

Vertebra,.... 

271 
103 
31 

220 
64 
36 

3 
I 

I 

202 

I178 
309 
83 

II 
II 

7 

1024 

132 

215 

200 

and  foot. 

119 

74 

and  hand. 

No 
Record. 

124 
161 

88 

21 
91 
45 

No 
Record. 

577 
iSi 

6 
8 

1S7 
235 
145 

702 

69 
157 
51 

18 

55 
27 

No 
Record. 

506 
104 
44 

7 
20 

10 

492 

3264 

1529 
678 

66 

164 

2420 

Total, . . 

405 

527 

2623 

740 

530           772 

1269 

377 

1183 

8426 

The  association  of  joint  tuberculosis  with  pulmonary  tuberculosis  is  difficult 
to  determine,  since  the  records  are  not  satisfactory.  In  investigating  this  sub- 
ject I  have  been  kindly  aided  by  Dr.  LawTason  Brown.     From  the  statistics 


CLASSIFICATION  AND  STATISTICS  OF  DEFORMITY.  95 

of  the  Adirondack  Cottage  Sanatarium,  Saranac  Lake,  N.  Y.,  it  was  found 
that  in  2000  cases  there  were  10  cases  of  tuberculous  disease  of  the  joints. 
These  illustrate  the  development  of  joint  tuberculosis  in  those  suffering  from 
chronic  pulmonary  tuberculosis.  They  were  distributed  as  follows:  hip,  5; 
knee,  3;  elbow,  i;  and  wrist,  i. 

These  statistics  do  not  show  the  real  frequency  of  such  affections,  as  only 
very  carefully  selected  cases  are  accepted  at  the  Sanatarium,  but  they  show 
in  a  degree  the  development  of  joint  tuberculosis  in  those  afflicted  with  pulmon- 
ary disease. 

Only  one  of  these  cases  had  laryngitis.  It  is  my  observation  that  this 
affection  is  very  rarely  associated  with  jomt  tuberculosis.  That  it  is  very  com- 
mon among  Indians  is  a  well-known  fact,  but  joint  tuberculosis  occurring  in 
Indians  sufi'ering  from  laryngitis  is  very  rare. 

Dr.  Hrdlicka,  of  the  Smithsonian  Institute,  U.  S.  National  Museum,  who 
has  made  a  special  study  of  tuberculosis  among  the  Indian  tribes,  has  given  me 
the  following  valuable  information  as  a  result  of  his  researches.  In  studying 
a  large  number  of  skeletons  of  Indians  of  a  very  early  period,  before  the  advent 
of  the  whites,  there  was  not  a  single  instance  of  tuberculous  lesion  of  the  bone  in 
a  plainly  discernible  form,  nor  were  any  lesions  that  were  found  of  such  a  nature 
as  even  to  suggest  tuberculosis  as  a  predisposing  cause.  Among  modern  Indians, 
however,  pulmonary  and  glandular  tuberculosis  are  frequent,  and  tuberculosis 
of  the  knee  and  also  of  the  hip  have  been  met  in  certain  localities.  Among 
the  Mescalero  Apaches,  in  New  INlexico,  deformities  have  been  noted  which 
were  probably  a  sequel  to  hip  disease.  Six  or  seven  such  cases  have  recently 
come  under  the  observation  of  Dr.  Hrdlicka.  Among  some  of  the  Sioux 
tribes  in  the  colder  regions,  and  also  among  the  Nez  Perce,  tuberculosis  in 
all  its  forms  is  prevalent. 

Joint  tuberculosis  is  very  prevalent  in  the  large  cities  of  this  country, 
but  in  certam  sections  it  is  practically  unknown  among  the  natives,  as  in 
the  pine  district  of  Georgia,  the  desert  region  of  Arizona,  and  the  forest  sec- 
tions of  the  Adirondacks. 


CHAPTER  IV. 

GENERAL  SYMPTOMS,   DIAGNOSIS,  AND   PROGNOSIS 
OF   DEFORMITY. 

Under  the  general  subject  of  symptoms  must  be  considered  not  only  those 
actual  deformities  of  the  parts  which  are  described  under  the  special  sections 
of  this  work,  but  more  particularly  the  effect  upon  the  individual  physically, 
mentally,  and  in  his  relation  to  his  environment. 

On  account  of  their  deformities  many  people  are  rendered  useless  to  the 
world  and  become  a  burden  to  the  community.  In  countries  where  military 
service  is  compulsory  the  difficulty  of  utilizing  deformed  persons  is  most  apparent. 
Unfortunately  deformity  occurs  most  frequently  among  the  poorer  classes,  add- 
ing a  heavier  burden  to  their  overtaxed  condition.  The  effect  of  a  deformed 
body  upon  the  individual  thus  afflicted  cannot  readUy  be  understood  by  normal 
persons.  Many  of  these  afflicted  ones  dwell  in  solitude,  like  the  black  dwarf 
of  Scott,  haunted  by  the  consciousness  of  their  own  deformity.  The  more 
ancient  writers  always  considered  that  deformed  persons  commonly  strove 
to  compensate  themselves  in  some  way  for  that  of  which  nature  had  deprived 
them,  and  they  are  described  by  these  older  writers,  and  by  Bacon,  Shakespeare, 
and  their  contemporaries,  as  being  generally  void  of  natural  affection,  inclined 
to  revenge,  and  with  their  natural  inclinations  not  obscured  by  discipline  and 
virtue.  They  are  supposed  to  carry  about  within  themselves  the  elements  which 
induce  contempt  and  derision,  and  they  make  a  constant  effort  to  deliver  them- 
selves from  this  contumely.  From  this  effort  they  gradually  become  bold 
and  unscrupulous,  avaricious,  and  vindictive. 

These  traits  which  have  been  attributed  to  the  deformed  are  not  so  com- 
monly credited  to  them  in  the  present  day,  since  the  deformities  themselves  are 
not  permitted  to  increase  to  so  great  a  degree,  and  the  attitude  of  the  world 
toward  the  deformed  is  not  what  it  was  in  centuries  past.  One  meets  many 
characters  like  Lady  Joan  in  Scott's  "Quentin  Durward,"  but  there  are  few 
diabolical  Quilps,  such  as  the  dwarf  so  vividly  portrayed  by  Dickens. 

The  effect  of  deformity  upon  the  intellect,  and  especially  the  psychic  pain 
which  deformed  persons  experience,  is  well  shown  in  their  physiognomy.     This 

96 


SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  DEFORMITY.  97 

has  been  referred  to  b)'  many  writers.  It  affects  equally  the  high  in  station 
and  the  low,  the  rich  and  the  poor,  without  respect  to  persons.  The  greatest 
of  all  English  writers  has  well  described  this  mental  suft'ering  in  many  of  his 
characters,  notably  the  Duke  of  Gloucester: 

"  Love  forswore  me  in  my  mother's  womb: 
And,  for  I  should  not  deal  in  her  soft  laws, 
She  did  corrupt  frail  nature  with  some  bribe 
To  shrink  mine  arm  up  like  some  wither 'd  shrub; 
To  make  an  envious  mountain  on  my  back, 
Where  sits  deformity  to  mock  my  body; 
To  shape  my  legs  of  an  unequal  size; 
To  disproportion  me  in  every  part; 

Like  to  a  chaos,  or  an  unlick'd  bear- whelp  > 

That  carries  no  impression  like  the  dam." 

—Henry  VI,  Part  3d,  Act  III,  Scene  II. 

One  facetious  English  writer.  Hay,  in  his  "Essay  on  Deformity  of  the  Human 
Body,"  sensibly  vindicates  the  deformed,  to  which  class  he  himself  belonged, 
against  the  stigma  which  has  been  placed  upon  them.  That  deformity  of  the 
body  does  not  necessarily  interfere  with  greatness  of  intellect  or  achievement 
of  great  deeds  is  evidenced  among  the  names  of  great  men  who  have  been 
deformed,  ^sop,  Alexander  the  Great,  Socrates,  and  Agesilaus  are  representa- 
tives of  the  ancients,  and  Pope,  Scott,  Talleyrand,  Byron,  Lord  Burleigh,  Men- 
delssohn, and  many  others  in  later  times,  are  examples  of  greatness  achieved 
in  spite  of  bodily  .deformity. 

The  sole  instance  of  the  mention  of  a  deformed  woman  in  the  classic 
poets  is  that  of  Cutilla,  a  centenarian,  to  be  found  in  Pliny  and  Juvenal. 

Attitude  in  Deformity. — The  peculiar  attitudes  assumed  by  individuals 
suffering  from  various  deformities  are  so  characteristic  that  they  may  be  con- 
sidered almost  pathognomonic. 

In  children  suffering  from  acute  epiphysitis  of  the  hip  the  attitude  upon  the 
back  and  with  the  thigh  flexed  and  rotated  outward  is  so  typical  that  the  affec- 
tion could  be  diagnosed  by  inspection  alone. 

In  acute  lumbar  abscess  the  position  of  the  child  resting  upon  all  four  ex- 
tremities in  the  quadrupedal  position  is  never  seen  in  any  other  intra-abdominal 
tumors. 

The  attitude  in  infantile  spinal  palsy  is  typical  and  dift'ers  markedly  from 
the  peculiar  position  assumed  by  a  child  suffering  from  lateral  curvature  result- 
ing from  pleuropneumonia. 


()S  ORTHOPEDIC  SURGERY. 

In  cerebral  palsy  the  idiotic  expression,  the  rigidity  of  the  extremities,  and 
the  deformed  feet  would  at  once  lead  to  a  correct  opinion  as  to  the  condition 
present. 

In  hip-joint  disease  the  child  stands  upon  the  sound  limb  with  the  other  one 
flexed  slightly  forward  and  with  the  body  poised  over  the  affected  limb  in  such  a 
manner  as  to  produce  a  characteristic  attitude. 

In  cer\acal  caries  the  head  is  frequently  held  to  one  side  and  supported  by 
one  or  both  hands  in  a  fixed  position,  the  attitude  of  which  is  so  characteristic 
that  it  could  not  be  confounded  with  any  other  condition. 

In  progressive  muscular  atrophy  the  marked  lordosis,  the  enlarged  calf 
muscles,  and  the  effort  which  the  individual  makes  to  balance  himself  produce 
an  attitude  which  is  at  once  unmistakable  from  that  of  any  other  nervous 
affection;  whUe  in  iliac  abscess  the  position  of  the  child  in  standing  with  the 
thigh  flexed  and  heel  elevated,  together  with  the  presence  of  a  kyphosis,  is  one 
which  could  not  be  mistaken  for  any  other  condition. 

Diagnosis. 

For  the  general  diagnosis  of  deformity,  bacteriology,  the  Rontgen  ray,  and 
accurate  mensuration  are  employed  as  well  as  all  the  methods  used  in  physical 
diagnosis. 

Many  conditions  may  be  recognized  by  inspection  alone,  but  in  all  cases 
the  examination  should  be  most  thorough,  as  mistakes  usually  occur  through 
incomplete  examination.  The  upper  part  of  the  body  may  be  inspected  first, 
and  this  may  be  covered  with  clothing  while  the  lower  part  is  inspected.  In 
young  children  the  complete  exposure  of  the  body  is  the  most  satisfactory 
method  of  making  a  thorough  examination.  In  aU  cases  of  joint  disease 
the  entire  extremity  should  be  carefully  examined  and  should  be  compared 
with  the  opposite  limb. 

Bacteriology. — The  importance  of  making  bacteriologic  tests  in  all  diseases 
of  the  joints  cannot  be  overestimated,  since  in  many  instances  a  correct  diag- 
nosis is  otherwise  impossible.  These  tests  should  be  repeated  from  time  to 
time. 

Mensuration. — For  the  purpose  of  recording  the  condition  present  many 
different  methods,  amounting  at  the  present  time  to  at  least  sixty,  are  employed. 
These  include  methods  from  the  most  simple  free-hand  drawing  to  life-size 
tracings  taken  with  elaborate  machines.  The  most  useful  tool  for  making 
outlines  is  the  lead  tape,  a  narrow  strip  of  solder  by  which  the  outlines  can  be 


Fig.  69. — Attitude  in  Acute  Epiphysitis  of  the  Hip. 


Fig.  70. — Attitude  in  Lumbar  Abscess. 


Fig.  71. — Attitude  in  Infantile  Spinal  Palsy.  Fig.  72. — Attitude   in   Lateral  Curvature  from 

Pleuropneumonia. 


Fig.  73. — Attitude  in  Cereer.al  Palsy.    Paraplegic 
Type. 


Fig.  74. — Attitude  in  Hip-joint  Disease. 


Fig.  75. — Attitude  in  Cervical  Caries. 


Fig.  76. — Attitude  in  Cervical  Caries. 


Fig.  77. — Attitude  in  Peogkessive  Muscular  Atrophy  Fig. 

(Pepper). 


>. — Contraction  op  Hip  from  Ili.ac  Abscess. 


SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  DEFORMITY 


105 


accurately  traced.  Measurements  made  with  the  caliper  or  with  the  pelvimeter 
are  very  valuable  and  should  not  be  omitted.  In  order  to  determine  the  in- 
equality of  the  lower  extremities  special  measuring  machines  have  been  devised, 
and  the  one  here  figured  (Figs.  8i  and  82)  will  be  found  rapid  and  useful. 

Impressions  of  the  feet,  pelmatograms,  should  be  made  for  purposes  of 
record,  and  may  be  taken  singly  or  they  may  be  taken  continuously  on  a  long 
sheet  of  paper.  There  are  many  different  ways  of  taking  these  impressions, 
the  simplest  of  which  is  to  anoint  the  foot  with  vaselin,  after  which  it  is  placed 
upon  a  piece  of  cardboard,  thus  transferring  the  impression.  A  glass  plate 
may  be  smoked  from  a  candle  or  lamp  and  the  impression  of  the  foot  trans- 


FiG.  79. — Rod  Scoliosometer. 


Fig.  80. — Rod  Scoliosometer. 


ferred  from  this  to  a  piece  of  white  cardboard.  The  patient's  foot  may  be  oiled 
and  then  placed  in  a  box  of  lamp-black  and  the  impression  transferred  to  a 
piece  of  white  cardboard,  or  else  in  a  box  filled  with  French  chalk  and  the  im- 
pression then  transferred  to  a  piece  of  black  cardboard.  The  best  and  most 
satisfactory  method,  at  the  present  time,  however,  was  suggested  by  Frei- 
burg, and  consists  in  covering  the  foot  with  a  solution  of  tannic  acid  from 
the  following  formula: 

Acid,  tannici, gr.  xx. 

Glycerini, fovij. 

Aquas, ad  fsiij. 

The  patient  then  stands  upon  a  piece  of  cardboard  and  the  outline  of  the  foot 


106  ORTHOPEDIC  SURGERY. 

is  traced  with  a  pencil.     As  soon  as  the  impression  dries  the  following  solution 
is  applied,  to  make  a  permanent  ink  impression  of  the  foot: 

Tr.  ferri  chlor., foiss. 

Alcohol, fSxj. 

Glycerini, f.5J- 

Continuous  impressions  are  particularly  useful  as  illustrative  of  the  gait 
in  certain  nervous  affections.  Thus  in  cerebral  palsy  the  impression  of  the 
right  foot  will  sometimes  be  on  the  left  side  of  the  paper  and  the  impression  of 
the  left  foot  will  cross  over  to  the  right  side  of  the  paper  from  the  overlapping 


Fig.  Si. — Author's  Machine  tor  MEAsrEixG 

IXEQUALITY   OF   LoWER   EXTREMITIES. 


Fig.  S2. — .'Author's  Macsdce  for  Measuring 
Inequality  of  Lower  ExTREiiixiES. 


of  the  legs.  The  position  of  the  feet  in  the  continuous  impressions  is  also  of 
value  as  indicating  the  amount  of  inversion  or  eversion  of  the  limbs. 

The  impression  of  a  normal  foot  is  very  difficult  to  obtain,  since  the  effect 
of  pressure  upon  the  shape  of  the  feet  shows  itself  at  a  very  early  age. 

A  most  important  manner  of  obtaining  records  of  deformity  is  by  means 
of  photographs.  These  should  be  taken  wdth  the  part  uncovered,  and  should 
always  be  taken  in  exactly  the  same  manner,  the  same  distance  from  the  camera, 
and  if  possible  by  the  same  person,  so  as  to  eliminate  the  personal  equation. 
The  value  of  the  photographs  may  be  increased  by  the  use  of  a  screen  made 
up  of  threads  placed  about  one  or  two  inches  apart.     The  patient  is  placed 


Fig.  83. — Impression  of  Normal  Feet. 


SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  DEFORMITY. 


109 


on  the  far  side  of  this  screen,  and  patient  and  screen  are  photographed  on  one 
plate.  Another  method  may  be  employed,  that  of  photographing  the  patient 
on  the  one  plate  and  making  a  second  exposure  of  the  screen;  or  still  a  third 
method  may  be  used,  of  using  a  screen  thrown  upon  a  negative  and  placing 
the  two  negatives  together  in  making  the  print.     Photographs  enlarged  to 


Fig.  84. — Screen  Photo. 


life-size  are  sometimes  valuable,  particularly  where   the   part  is   small,  as  in 
children. 

The  discovery  of  the  Rontgen  ray  and  its  application  to  surgery  has  rendered 
the  diagnosis  of  many  obscure  orthopedic  affections  very  simple.  In  ortho- 
pedic practice  it  is  usually  best  to  take  a  photograph  of  the  corresponding  joint 


110  ORTHOPEDIC  SURGERY. 

on  the  opposite  side  at  the  same  time  as  that  of  the  diseased  joint;  and  when 
it  is  possible  it  is  best  to  take  them  upon  the  same  plate,  placing  the  tube  mid- 
way between  the  joints.  Such  photographs  as  this  can  readily  be  compared, 
and  if  the  parts  are  held  in  exactly  the  same  position  the  diagnosis  is  rendered 
easier.  To  avoid  motion  of  the  part  and  to  render  the  tissues  less  bulky  be- 
tween the  tube  and  the  anterior  portion  of  the  joint  a  compression  cylinder 
may  be  used  to  advantage,  and  the  one  made  in  this  country  is  to  be  recom- 
mended. This  also  has  the  advantage  of  concentrating  the  light  and  increas- 
ing its  penetrating  power.  It  is  of  decided  advantage  where  the  deep  struc- 
tures are  to  be  taken.  In  order  to  compare  the  diseased  parts  with  normal 
conditions  it  is  always  best  to  have  convenient  photographs  of  normal  joints. 

Another  very  important  manner  of  preserving  records  is  by  the  use  of 
plaster  casts  or  wax  models.  The  way  in  which  these  are  taken  is  the  same 
as  that  employed  by  the  Italian  plaster  modelers. 

In  keeping  all  records  of  deformities  both  in  private  and  public  work  elaborate 
printed  forms  are  sometimes  used  to  great  advantage,  as  in  this  manner  im- 
portant questions  are  not  overlooked  in  the  anamnesis. 

Prognosis. 

Confirming  the  opinion  of  an  early  writer,  Little,  it  may  be  truthfully 
said  at  the  present  time  that  many  of  the  most  severe  deformities  can  be  cured 
with  less  difficulty  than  any  other  difficulties  or  affections  which  are  at  all  com- 
parable in  the  amount  of  mental  and  bodily  suffering  involved.  The  prog- 
nosis will  depend  greatly  upon  the  time  when  treatment  is  undertaken,  since 
many  deformities  are  rendered  more  difficult  of  treatment  by  reason  of  the  bony 
changes  which  occur.  Thus  in  club-foot,  scoliosis,  and  rachitic  deformities 
the  occurrence  of  permanent  bony  changes  makes  the  cure  much  more  difficult. 

The  occurrence  of  spontaneous  cures  is  exceedingly  rare.  In  club-foot 
there  have  been  recorded  but  two  cases  which  have  recovered  without  treat- 
ment. One  of  these  was  a  boy,  the  son  of  a  miller,  in  France,  reported  by 
Dupuytren,  who  was  induced  by  his  parent  to  carry  a  heavy  load  of  grain  upon 
his  shoulder  and  to  place  his  foot  in  a  certain  position  upon  the  ground,  result- 
ing in  a  cure  by  the  time  he  had  reached  the  age  of  twenty.  The  other  was  a 
negro  reported  by  the  writer  who  suffered  from  club-foot  untU  he  was  twenty 
years  of  age.  From  this  time  until  his  twenty-sixth  year  his  feet  gradually 
began  to  turn  out,  from  the  natural  tendency  to  flat-foot  present  in  this  race, 
until  he  finally  recovered. 


Fig.  8;. — Normal  Hip.     X-Ray. 


Fig.  86. — Normal  Knee.    X-Ray. 


Fig.  87. — Kelly-Koett  Machine  for  Making  X-Rays,  showing  Compression  Cylinder. 


Fig.  88.— Kelly-Koett  Machine  por  Maki.ng  X-Rays  Applied. 


SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  DEFORMITY.         117 

Spontaneous  recovery  from  rachitic  deformities  sometimes  occurs  from 
muscular  development  while  the  bones  are  still  soft,  but  if  the  disease  has 
reached  the  hardening  process  spontaneous  recovery  is  not  likely  to  occur. 
With  the  exceptions  mentioned,  deformity  either  remains  stationary  or  else 
becomes  gradually  v^^orse. 

The  results  of  treatment  of  deformities  are  astonishing,  particularly  when 
surgical  operations  are  first  performed,  and  are  followed  by  thorough  orthopedic 
treatment.  Very  frequently  when  the  deformity  is  too  severe  for  a  cure  to  be 
eflfected  it  may  yet  be  so  treated  that  the  disease  may  be  checked,  and  the 
patient  rendered  comparatively  comfortable. 


CHAPTER    V. 
PROPHYLAXIS  AND  GENERAL  TREATMENT. 

More  important  than  the  actual  treatment  of  bodily  deformities  is  the 
prophylaxis,  or  prevention,  by  the  employment  of  every  means  which  will  im- 
prove the  physical  condition  of  the  patient.  Under  this  title  should  be  included 
not  only  the  complete  hygiene  of  the  individual  but  the  development  of  the 
osseous  and  muscular  systems  by  means  of  gymnastics  and  sports.  The  physical 
examination  of  children  in  public  and  private  schools  marks  an  important 
advance  in  this  direction.  Not  only  is  the  child  better  fitted  for  its  future  work 
by  the  physical  examination,  but  any  early  deformity  is  recognized  by  the 
trained  examiner  and  may  be  corrected  before  it  becomes  permanent. 

The  establishment  of  public  institutions  by  the  State  and  by  private  in- 
dividuals for  the  correction  and  treatment  of  the  deformed  is  characteristic 
of  the  progress  which  has  been  made  in  this  line.  The  State  Hospitals  of 
New  York,  Minnesota,  and  of  many  other  States,  are  model  institutions  of  their 
kind,  and  the  private  institution,  the  Widener  Home  for  the  Crippled  and  De- 
formed, of  Philadelphia,  erected  at  a  cost  of  two  million  dollars  by  its  gen- 
erous donor,  is  far  superior  to  anything  that  has  yet  been  conceived  along 
these  lines.  Not  only  are  the  deformed  cared  for  and  treated,  but  their  edu- 
cation and  future  welfare  are  insured. 

Under  the  head  of  prophylaxis  we  may  consider  the  early  treatment  of 
congenital  deformities,  since  this  prevents  the  development  of  the  severer  de- 
formities and  admits  of  their  correction  before  they  have  become  extreme. 

The  greater  care  and  the  more  extensive  knowledge  in  regard  to  the  treat- 
ment of  joint  disease  at  the  present  time  prevent  the  crippling  and  distressing 
deformities  which  were  formerly  so  common  in  this  condition,  and  where  the 
joint  disease  cannot  be  cured  the  setting  of  the  limb  in  such  a  position  as  to 
insure  its  greatest  usefulness  should  be  considered  under  the  head  of  preventive 
measures.  Thus,  the  knee  and  hip  are  set  straight,  and  the  elbow  and  foot 
are  flexed  at  a  right  angle. 

The  prevention  of  such  diseases  as  are  caused  by  neglect  and  exposure 
calls  for  consideration  here.     Since  a  certain  number  of  cases  of  infantile  paraly- 


PROPHYLAXIS  AND  GENERAL  TREATMENT.  119 

sis  are  due  to  the  chilling  of  the  surface  of  the  body  when  the  patient  is  over- 
heated, the  prevention  of  conditions  which  lead  to  this  result  would  in  many 
instances  forestall  the  development  of  this  serious  condition. 

The  proper  feeding  of  infants  through  municipal  aid  and  private  charities 
is  of  great  service  in  preventing  the  occurrence  of  rickets,  and  at  the  present 
time,  when  rickets  is  becoming  more  frequent  in  the  large  cities  of  this  country, 
attention  should  be  directed  to  this  means  of  prevention.  The  establishment  of 
modern  sanitary  farms  enables  the  rich  to  obtain  pure  milk,  and  in  this  way 
escape  many  of  the  dangers  of  rickets  and  of  tuberculosis. 

The  prevention  of  nervous  diseases  due  to  mineral  poisons,  illuminating 
gas,  and  sepsis,  should  all  be  considered  under  the  head  of  preventive  medicine. 

General  Treatment. 

In  addition  to  the  local  and  special  treatment,  which  will  be  described 
later,  it  is  necessary  to  take  into  consideration  the  constitutional  treatment 
of  the  deformed.  This  includes  everything  which  will  improve  the  physical 
condition  of  the  afflicted,  and  especially  as  to  diet,  exposure  to  sunlight,  and 
change  of  residence,  together  with  such  medical  and  general  treatment  as 
may  be  indicated  by  the  special  requirements  of  the  case. 

Diet. — The  study  of  the  proper  diet  of  infancy  and  childhood  has  received 
so  much  attention  of  late  that  it  is  only  necessary  to  call  attention  to  the  im- 
portance of  securing  a  proper  diet  for  those  who  are  deformed. 

Sunlight. — In  no  class  of  diseases  is  exposure  to  sunlight  so  important 
as  in  the  treatment  of  tuberculous  joint  disease,  which  is  productive  of  such 
a  large  number  of  deformities.  So  important  is  the  use  of  solariums  that  many 
institutions  at  the  present  time  have  sun-parlors  attached  to  the  orthopedic 
wards,  and  the  beneficial  effects  of  this  form  of  treatment  are  so  marked  as 
to  attract  the  attention  of  aU  who  are  interested  in  the  subject. 

Change  of  Residence. — ^A  change  of  residence  to  the  seashore  or  moun- 
tains is  often  most  valuable  to  give  that  impetus  which  is  necessary  for  the 
cure  of  cases  of  joint  tuberculosis.  So  important  is  a  residence  at  the  seashore 
for  part  of  the  year  that  public  institutions  have  been  established  for  the  care 
of  the  indigent,  and  the  marked  benefit  to  these  cases  can  scarcely  be  over- 
estimated. Personally  I  have  seen  cases  which  would  otherwise  have  been 
fatal  make  a  good  recovery  within  two  or  three  months.  When  there  is  a 
nervous  element  in  the  patient,  a  change  to  a  higher  altitude  is  frequently 


120  ORTHOPEDIC  SURGERY. 

more  beneficial  than  to  the  seashore,  or  a  change  to  the  mountains  may  suc- 
ceed a  short  stay  at  the  seashore. 

Medical  Treatment. — The  medical  treatment  includes  the  use  of  tonics, 
particularly  the  salts  of  iron,  with  the  use  of  hypophosphites.  In  tuberculous 
cases  cod-liver  oil  is  found  to  be  of  great  value,  and  in  some  joint  lesions  the 
use  of  mineral  waters  or  a  residence  at  a  mineral  spring  is  found  to  be  of  signal 
benefit. 

Electricity. — The  application  of  electricity  in  the  treatment  of  orthopedic 
cases  should  not  be  neglected.  The  faradic  current  will  be  found  to  be  more 
useful  than  the  galvanic,  and  the  frequently  interrupted  should  be  preferably 
employed  for  the  general  nutrition  of  the  parts.  The  local  application  of  either 
the  faradic  or  galvanic  current  to  the  motor  points  is  of  great  service  in  many 
orthopedic  cases.  The  special  application  of  electricity  to  the  individual  affec- 
tions will  be  dealt  with  at  greater  length  under  the  various  subjects.  Occasion- 
ally galvanopuncture  of  the  muscles  by  means  of  a  needle  is  of  value. 

Gymnastics. — The  conflicting  discussions  which  prevailed  during  the 
past  century  have  now  been  settled  by  the  general  adoption  of  medical  gym- 
nastics in  the  treatment  of  orthopedic  affections.  Especially  valuable  is  the 
method  originated  by  Ling,  known  as  the  Swedish  system.  The  practice  of 
Swedish  gymnastics  today  is  based  largely  upon  empiricism,  since  many  of 
the  theories  held  by  the  founder  are  untenable. 

Sequence  of  movement  is  the  most  important  feature  of  this  system,  using 
simple  movements  followed  by  combinations  of  movements,  complex  move- 
ments, and  finally  exercises  which  include  the  general  action  of  the  entire  body. 
Of  the  four  special  divisions  of  the  Swedish  system,  the  pedagogic  or  school 
gymnastics,  military  gymnastics,  medical  gymnastics,  and  esthetic  gymnastics, 
we  are  concerned  only  with  the  third  group.  In  orthopedic  treatment  the 
medico-gymnastic  exercises  include  respiratory  exercises,  general  health  exer- 
cises, and  exercises  which  are  used  in  the  correction  of  lateral  curvature.  The 
proper  order  in  which  the  exercises  should  be  given  is  also  of  importance,  and 
the  following  order  is  the  one  which  is  most  generally  employed,  being  subject 
to  modifications  in  certain  cases:  a  respiratory  movement  is  first  given,  which  is 
followed  by  a  movement  of  the  lower  extremities  and  of  the  upper  extremities; 
then  follows  a  movement  of  the  abdomen  and  trunk,  followed  by  a  movement 
of  the  lower  extremities,  and  finally  ending  with  a  respiratory  movement.  This 
practice  of  beginning  with  a  respiratory  movement,  leading  up  to  more  violent 
movements  of  the  trunk,  and  gradually  returning  to  the  respiratory  movement, 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


121 


with  which  to  end,  is  of  advantage  in  gradually  allowing  the  accelerated  action 
of  the  heart  to  become  slow,  and  also  to  permit  the  gradual  lessening  of  the 
perspiration  caused  by  the  exercises.  The  system  also  requires  that  each 
movement  shall  be  taken  from  a  starting  position.  The  movement  should 
be  carefully  carried  out  from  this  first  position  and  the  body  returned  to  the 
same  position.  There  are  five  fundamental  positions — standing,  sitting,  lying, 
hanging,  and  kneeling. 

The  movements  are  either  active  or  passive,  and  in  many  of  the  medical 
gymnastics  they  are  subjectively  passive,  the  exercises  being  carried  out  by  the 


manipulator.  All  of  the  exercises  required  for  the  treatment  of  deformities  are 
special,  and  should  be  prescribed  by  the  surgeon.  Most  of  the  systems  which 
are  usually  employed  in  the  work  of  general  development  are  not  suited  to 
orthopedic  work,  since  they  employ  the  muscles  on  both  sides  of  the  body  and 
cannot  be  adapted  to  the  treatment  of  special  deformities.  The  subject  of 
physical  development  is  so  extensive  that  it  is  impossible  to  deal  with  it  in  a 
general  way,  and  the  reader  is  referred  to  Cohen's  "Physiologic  Therapeu- 
tices,"  volume  vii,  and  Keating's  "Cyclopedia  of  the  Diseases  of  Children," 
volume  IV. 


122 


ORTHOPEDIC  SURGERY. 


Mechanical  Gymnastics. — The  introduction  of  machines  for  physical 
development  has  greatly  enlarged  the  scope  of  this  department,  and  has  pro- 
duced a  branch  of  gymnastic  treatment  which  may  be  spoken  of  as  the  medico - 
mechanic.  Elaborate  machines  covering  an  extensive  field  have  been  pro- 
vided in  this  country  by  the  Sargent  system,  and  in  Europe  by  the  Zander 
system.  These  differ  vi^idely  in  appearance  and  use.  The  Sargent  apparatus 
is  adapted  to  the  development  of  any  part  of  the  body,  from  a  single  finger  to 
the  muscles  of  the  entire  back.     When  used   in  gymnasiums,  this  system  is 


Fig.  90. — Passive  Rotation. 


employed  only  after  a  thorough  physical  examination  of  each  individual,  and 
the  special  prescription  of  exercises  to  overcome  particular  defects.  For  ortho- 
pedic treatment  the  special  exercises  are  prescribed  by  the  surgeon  according 
to  the  development  desired  for  the  individual  condition. 

The  Zander  machines  include  two  forms,  those  which  are  intended  for 
the  application  of  massage  and  those  which  are  "used  for  the  production  of 
movements,  passive,  active-passive,  and  resistive.  They  are  very  elaborate, 
and  include  machines  for  the  treatment  of  every  portion  of  the  body,  being 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


123 


run  by  motive  power.     In  this  respect  they  differ  from  the  Sargent  apparatus, 
which  is  manipulated  by  the  patient. 

From  these  two  types  of  machines  numerous  modifications  have  been 
devised  both  in  this  country  and  abroad,  so  that  the  number  in  use  at  the 
present  time  is  legion.     A  special  form  of  apparatus  has  of  late  been  contrived 
which  may  be  described  as  the  pen- 
dulum  apparatus,  the  motive  power 
being  the  individual  and  the  resist- 
ance being  by  means  of  weights,  and 
the   action  is   that   of  a  pendulum. 
Appliances  have  been  manufactured 
upon  this  principle  by  Beely,  Hoffa, 
and  others. 

Special  machines  have  been  de- 
vised for  the  correction  of  deformity, 
especially  for  lateral  curvature  of  the 
spine.  These  may  all  be  included 
under  two  types — the  Hoffa  machine, 
combining  self-suspension  with  local 
pressure,  and  the  Beely  machine, 
which  omits  the  suspension  and  ap- 
plies the  pressure  by  means  of  bands 
and  straps.  The  best  representative 
type  of  the  correcting  machine  is  the 
"Weigel-Hoffa,"  which  is  used  for 
correcting  lateral  curvature. 

The  most  recent  therapeutic 
agent  which  has  been  introduced 
into  orthopedic  practice  is  vibration. 
This  may  be  given  by  hand-power 
or  by  electricity.     From  one  to  two 

thousand  blows  may  be  given  a  minute,  and  the  accuracy  and  evenness  of 
these  movements  are  much  greater  than  can  be  given  by  the  human  hand. 

Massage. — ^A  very  valuable  form  of  passive  exercises  by  systematic  manual 
manipulation  of  the  affected  part  for  therapeutic  purposes  is  known  as  massage. 
Scientifically  applied  it  influences  the  muscular,  nervous,  circulatory,  and 
digestive  systems.     It  is  most  valuable  in  orthopedic  practice  to  prevent  atrophy 


pi. — Weigel-Hofpa  Correcting  Machine^for 
Lateral  Curvature. 


124  ORTHOPEDIC  SURGERY. 

of  the  muscles,  to  develop  muscular  power,  to  stimulate  nerve  action,  and  as 
a  sedative  to  the  central  nervous  system.  Properly  applied  it  is  an  art,  and  has 
a  most  beneficial  effect,  but  improperly  applied  it  has  a  very  deleterious  effect 
upon  the  patient.  For  this  reason  it  should  be  very  carefully  prescribed  by 
the  surgeon  as  to  the  movements  to  be  given,  the  method,  time,  etc.  It  is  most 
skilfully  applied  by  a  warm,  dry  hand,  without  any  lubricant. 

Five  different  movements  are  recognized — effleurage,  petrissage,  friction, 
tapotement,  and  vibration.  Under  these  heads  may  be  included  all  move- 
ments which  are  given  under  the  general  term  of  massage,  although  some 
authorities  have  subdivided  them  into  more  than  sixty  heads. 

By  effleurage  is  meant  a  rhythmic  stroking  of  the  part,  employing  the  fiat 
of  the  hand,  the  edge  of  the  hand,  the  thumbs,  the  thumbs  and  finger-tips, 
according  to  indications.  It  is  always  applied  with  a  centripetal  movement 
and  a  certain  amount  of  pressure  is  used.  The  movements  should  be  given 
rhythmically,  beginning  slowly,  increasing  the  speed  somewhat,  and  terminating 
with  a  slow  movement. 

The  movement  known  as  petrissage  consists  in  grasping  and  kneading 
the  part  by  alternately  tightening  and  loosening  the  grasp,  and  lifting  and 
alternately  rubbing  with  the  flat  of  the  hand,  keeping  the  fingers  close  together 
and  moving  the  skin  beneath  the  hand.  The  special  movements  included 
under  this  division  are  varied  to  suit  the  individual  requirements,  being  des- 
cribed as  fulling,  rolling,  wringing,  fist-kneading,  etc.  Petrissage  is  the  most 
important  movement  used  in  general  massage,  producing  a  direct  stimulation 
to  the  muscles,  increasing  the  venous  and  lymphatic  circulation,  and  indirectly 
affecting  the  articular  circulation. 

The  movement  known  as  friction  is  applied  with  the  thumb  or  tips  of  the 
fingers  in  small  circles, — centripetal  rubbings, — a  certain  amount  of  pressure 
being  used  throughout  the  movement.  It  is  most  valuable  in  chronic  and 
subacute  affections  for  the  purpose  of  removing  exudates. 

Tapotement,  or  tapping,  consists  in  a  series  of  rapid  percussions  with  the 
finger-tips,  percussion;  with  the  edge  of  the  hand,  hacking;  with  the  flat  of  the 
hand  {tnain  plat),  slapping;  with  the  closed  hand  (a  poing  jerme);  and  with 
the  surface  of  the  hand  hollowed  out  like  a  cup  (a  air  imprime),  cup-hand 
slapping.  Tapotement  with  the  knuckles  is  occasionally  employed.  The 
application  of  tapotement  is  limited.  The  slapping  movements  are  used  to 
stimulate  the  superficial  nerves,  and  the  hacking  movement  is  applied  to  the 
muscles  throughout  their  entire  length. 


Fig.  02. — Effleue.\ge  of  Spine. 


Fig.  93. — Petrissage. 


Fig.  94. — Friction. 


Fig.  05. — Thumb  Sep.\k.\ting  ox  B.\ck. 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


129 


The  movement  of  vibration  is  a  rapid,  shaking  movement  with  the  flat 
of  the  hand  or  with  the  fingers  extended  on  the  part.  It  is  the  only  movement 
which  can  be  applied  with  a  machine  as  well  as  with  the  hand. 

Massage  should  be  given  only  once  a  day  and  should  at  first  be  applied 
about  twenty  minutes,  the  time  being  gradually  extended  to  forty  minutes. 
This  rule  holds  good  ordinarily,  but  if  it  is  a  local  treatment,  as  for  a  joint, 
it  may  be  employed  two  or  three  times  daily  for  from  five  to  ten  minutes,  and 
where  there  is  much  pain  following  the  manipulations,  it  would  have  to  be  given 


Fig.  g6. — Flat-hand  Kneading. 


only  once  in  two  or  three  days.     It  should  not  be  given  for  about  two  hours 
before,  and  three  hours  after,  a  meal. 

Heat.— The  application  of  hot  air  is  valuable  in  the  treatment  of  joint 
affections,  and  may  be  applied  by  inclosing  the  part  in  a  superheated  chamber. 
The  part  must  be  carefully  wrapped  in  lint  and  toweling  to  absorb  the  moisture 
which  is  given  off.  The  apparatus  should  be  lined  with  asbestos  and  the  part 
suspended  upon  a  flat  form  of  muslin  or  asbestos.  Special  apparatus  for  the 
local  application  of  heat  has  been  devised,  notably  the  Tellerman-Sheffield  and 
the  Frazier-Lentz  apparatus.  .The  principle  is  the  same  in  any  such  apparatus, 
the  part  requiring  treatment  being  inclosed  in  the  superheated  chamber, 
the  temperature  being  generated  by  gas  or  oil,  and  being  carefully  regulated 

10 


130 


ORTHOPEDIC  SURGERY. 


by  means  of  a  thermometer.  In  the  Frazier-Lentz  apparatus  the  temperature 
may  be  carried  to  350°  F.,  but  it  is  not  necessary  to  employ  so  extreme  a  degree 
of  heat  in  order  to  accomplish  satisfactory  results.  The  effect  of  the  applica- 
tion of  hot  air  is  to  produce  a  local  sweating  and  congestion  of  the  part.  The 
temperature  should  be  raised  gradually,  maintained  at  the  maximum  for  some 
time,  and  allowed  gradually  to  cool,  the  amount  of  time  consumed  in  the  entire 
process  being  from  twenty  to  forty  minutes.  If  the  parts  are  properly  covered 
and  the  temperature  is  not  excessive,  there  should  be  but  little  danger  of  burn- 
ing the  part;   and  if  applied  carefully,  the  hot-air  treatment  is  frequently  very 

beneficial,  and  burns  seldom  occur. 
This  form  of  treatment  is  most  use- 
ful in  traumatic  arthritis,  rheumatoid 
arthritis,  sprains,  chronic  articular 
rheumatism,  and  septic  arthritis.  In 
many  chronic  conditions  the  results 
of  the  application  of  heat  are  in- 
creased by  the  administration  of 
massage  after  the  application  of  the 
heat. 

Local  Treatment. 

The   local    treatment  of   ortho- 
pedic affections  consists  in  the  ap- 
plication of  apparatus  and  appliances, 
and  in  orthopedic  surgical  operations. 
In  prescribing  apparatus  for  patients  it  is  very  important  that  very  care- 
ful and  accurate  outlines  of  the  measurements  should  be  secured. 

These  are  taken  in  several  different  ways  by  the  practical  surgeon.  For 
example,  in  taking  the  outlines  for  the  measurements  of  bow-leg  braces, 
some  employ  a  drawing  showing  the  circumference  of  the  parts.  In  others 
the  outline  represents  the  side  view  of  the  apparatus  to  be  used,  while  a  third 
form  employed  is  to  take  a  drawing  of  the  elevation  of  the  parts  viewed  from 
the  front.  When  the  deformity  is  great,  the  outlines  of  the  limbs  traced  upon 
paper  is  of  service  to  the  instrument-maker. 

In  taking  outlines  for  spine  braces  and  outlines  of  parts  that  are  greatly 
deformed  the  lead  strip  is  most  frequently  employed.  This  is  applied  directly 
to  the  deformity,  and  the  outline  is  then  drawn  on  cardboard  or  pressboard. 


Fig.  97. — Frazier-Lentz  Hot-air  Apparatus. 


Perineum 

Line  top  middle  3d  of  thigh 


Line  top  lower^3d  of  thigh 


Ankle-joint 
Sole  of  foot 


Upper  border  scapula 


Waist 

Crest  of  ilium 
Middle  of  sacrum 
Top  of  natal  creas* 

Trochanter 


Length 

-Outline  for  Measurements  of  Spinal  Apparatus  and  Lower  Extremity. 


Fig.  99, — Outline  of  Sole. 


Outlines  for  Measurements. 


u 


Fig.  ioo. — Outline  eor      Fig.  ioi.— Outline      Fig.  102. — Outline 
Bow-legs  Braces.  for  Bow-legs  foe  Bow-legs 

Braces.  Braces. 


Fig.  ios. — Outline  for   Bow-legs. 


Band    for    Tay- 
lor hip  splint. 


Fig.  105. — Outline  for  Taylor  Hip  Splint. 


Band    for    Tay-         I  | 

lor  spine  brace. 


Fig.  104. — Outline  for  Taylor 
Spine  Brace. 


Fig.    107. — Measurement 
FOR  Leg  Brace. 


Fig.  ioS. — Outlike 
for  Ankle  Sup- 
port. 


Fig.  106. — Measure- 
ment FOR  Thomas 
Htp  Splint. 


Outlines  for  Measurements. 


Fig.  112. — Extension  Joint.    Fig.  113. — Drop-catch  Joint.       Fig.  114. — Congdon  Joint.        Fig.  115. — Free  Joint. 


0 
0 

0 
0 

0 


r\ 


o 


© 


\Oj 


^ 


UJ 


u 


Fig.   116. — Extension       Fig.  117. — Ratchet  and  Fig.  118. — Free  Joint.  Fig.   iig. — Sector  Joint. 

Joint.  Pinion  Joint. 


Fig.  120. — Free  Joint.         Fig.  121. — Detachable 
Joint. 


[iFiG.^122. — Free  Joint.  [    |   Fig.  123. — Stop  Joint. 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


139 


If  the  pressboard  is  used,  this  may  be  cut  out  and  verified  by  applying  it  to 
the  deformity. 

The  proper  taking  of  measurements  for  braces  requires  considerable  ex- 
perience, which  can  be  gained  only  by  actual  practice.  The  outlines  which 
are  here  given  are  those  which  are  almost  universally  employed,  and  can  be 
used  with  advantage  by  instrument-makers  in  constructing  apparatus  pre- 
scribed by  the  surgeon. 

For  the  fitting  of  apparatus  surgeons  require  certain  orthopedic  tools, 
the  most  important  of  which  are  the  bending  irons  or  "crows"  and  the  bending 
forceps.  The  other  tools,  which  include  screw-driver,  stillette,  and  different 
forms  of  keys,  are  sometimes  combined  in  a  portable  set.  In  using  the  bending 
irons  they  should  be  placed  upon  the  same  side  of  the  steel  and  parallel  with 


Fig.  124. — Rubber  Muscles. 


Emosm — CO 
]  Li     1J5  — I  LUB-FOOT  Shoe. 
A,  upper;  B,  steel  upright; 
G,  steel  arch. 


each  other  and  the  bending  should  be  effected  by  separating  the  ends  which 
are  not  attached  to  the  steel.  By  using  them  in  this  manner  and  avoiding 
screw-holes  steel  may  be  bent  without  breaking. 

Joints. — The  most  important  parts  of  orthopedic  apparatus  are  the  joints. 
The  simplest  combination  which  constitutes  a  joint  is  known  as  the  free  joint. 
This  consists  of  two  pieces  of  metal  fastened  together  with  a  pin  and  permitting 
of  motion  in  two  directions  like  a  hinge.  In  order  to  prevent  friction  and  wear- 
ing of  the  parts  these  are  usually  made  more  elaborate  by  forgings  and  the 
addition  of  separate  pieces,  and  in  some  cases  they  are  made  detachable.  The 
detachable  joints  are  most  useful  at  the  ankle-joint,  since  by  employing  a  joint 
of  this  kind  different  pairs  of  shoes  may  be  used  with  the  same  brace.  In 
addition  to  the  free  joint  we  have  the  lock  joints  of  different  kinds.  These 
may  be  of  the  simplest  form,  as  the  ring  or  drop  catch,  or  they  may  be  a  more 


140 


ORTHOPEDIC  SURGERY. 


elaborate  arrangement  known  as  the  Congdon  joint,  or  a  still  more  elaborate 
one,  the  trigger  joint.  When  extension  is  desired,  the  rack  and  pinion  extension 
joint  is  the  one  most  generally  in  use;  and  when  fixation  is  desired  in  different 
positions,  the  universal  ball-and-socket  joint  is  usually  employed,  as  in  the  attach- 
ment of  the  head-piece  for  cervical  caries  or  in  the  different  forms  of  club-foot 
shoes.  A  free  joint  is  sometimes  fixed  at  certain 
points,  when  it  is  known  as  a  stop  joint.  By 
means  of  these  stop  joints  motion  is  limited, 
and  they  find  very  frequent  employment  at  the 
ankle,  knee,  and  hip.     A  variety  of  fixed  joint 


Fig.  126. — Taylor  Spine  Brace,  showing  Finished  Appa- 
ratus. 


Fig.  127. — Paralysis  Brace, 
SHOWING  Finished  Appara- 
tus. 


which  is  sometimes  found  useful  is  the  sector  splint.  This  consists  of  a  semi- 
circular plate  of  steel  fastened  to  the  upright  and  permitting  of  adjustment 
at  certain  angles  by  means  of  screws  or  pins.  These  are  very  useful  about 
the  knee-joint. 

Leg  braces  are  usually  attached  to  the  shoes  by  means  of  stirrups,  and 


PROPHYLAXIS  AND  GENERAL  TREATMENT.  141 

these  are  made  in  a  great  variety  of  shapes  and  forms.  Springs  are  used 
in  connection  with  braces  to  apply  traction  or  pressure.  These  may  be 
made  of  finely  tempered  steel  or  of  spiral  steel,  and  in  some  instances 
rubber  muscles  are  used,  especially  in  paralytic  deformities,  to  assist  the 
weak  muscles.  In  the  treatment  of  club-foot  special  apparatus  is  used,  and 
all  forms  of  club-foot  shoes  are  fashioned  upon  the  principle  of  the  Scarpa 
shoe,  in  which  the  power  is  transmitted  by  an  Archimedean  screw.  Rubber 
muscles  have  also  been  used  in  connection  with  this  apparatus,  as  in  the  Sa3Te 
club-foot  shoe. 

The  finishing  of  apparatus  is  largely  a  matter  of  personal  fancy,  since  if 
the  principle  upon  which  the  apparatus  is  applied  is  correct,  an  elaborate  finish 
is  a  matter  of  secondary  importance.  It  is  very  important  in  all  cases  that 
apparatus  should  be  prescribed  by  the  surgeon,  and  that  patients  should  not 
be  permitted  to  select  their  own  braces  from  catalogues,  and  much  less  should 
instrument-makers  sell  braces  to  patients.  In  every  case  the  apparatus  should 
be  made  to  order  for  the  individual,  and  neatness,  lightness,  and  strength  of 
construction  should  be  carefully  studied  by  the  surgeon,  and  every  effort  put 
forth  to  assure  the  production  of  a  completed  apparatus  which  will  at  once 
be  elegant  in  appearance  and  yet  as  inconspicuous  as  possible,  since  the 
deformed  are  usually  hypersensitive. 

Orthopedic  Apparatus  and  Appliances.— In  addition  to  iron  and  steel, 
which  are  most  commonly  employed,  aluminum,  brass,  bronze,  plaster,  wood, 
hard-rubber,  celluloid,  paper,  etc.,  have  been  used  in  the  construction  of  ortho- 
pedic appliances.  When  apparatus  is  manufactured  in  regular  shops,  the 
finest  steel  is  used,  as  a  rule,  but  many  useful  appliances  may  be  made 
in  any  part  of  the  country  from  materials  which  are  at  hand.  Every 
practitioner  should  be  prepared  to  apply  plaster-of-Paris  dressings.  Wood 
may  be  used  in  the  preparation  of  splints  or  to  reinforce  the  plaster-of-Paris 
dressings. 

In  orthopedic  practice  the  use  of  adhesive  plaster  is  very  general,  the  plaster 
being  spread  upon  heavy  canton  flannel.  The  best  of  this  plaster  is  the 
Maws  moleskin  plaster,  made  in  London,  and  the  Shiver  swansdown  plaster, 
made  in  Philadelphia.  When  applied  for  purposes  of  traction,  the  plaster 
is  cut  into  many-tailed  bandages  and  is  applied  to  the  limb  by  overlapping. 
The  dressing  is  then  held  in  place  by  a  muslin  roller,  which  is  either  sewed 
or  secured  with  a  strip  of  adhesive  plaster. 

Adhesive  plaster  dressings  are  very  frequently  employed  to  make  pressure 


142 


ORTHOPEDIC  SURGERY. 


upon  the  joints  or  to  strengthen  them  after  sprains.  The  Gibney  or  Cottrell 
dressing  for  sprained  ankle  is  an  excellent  example  of  the  method  of  appl)dng 
this  variety  of  dressing. 

Couch  or  Bed  Bandages. — The  adhesive  plaster  dressing  is  used  for 
traction  with  the  patient  placed  upon  a  couch  or  bed,  with  the  limb  elevated 
or  abducted,  in  order  to  overcome  deformity.  Different  forms  of  this  variety 
of  traction  appliances  have  been  devised,  among  which  may  be  mentioned 
as  especially  valuable  the  Freiburg  extension  (and  the  Taylor  extension). 

Bed  bandages  are  more  or  less  elaborate  appliances  which  are  used  in 
correcting  deformity  while  the  patient  is  in  the  recumbent  position.  The  pa- 
tient may  be  suspended  by  a  sling  of  canvas,  leather,  or  other  material,  the 


Fig.  128. — Traction  Plaster. 


body-weight  being  used  as  a  counter- extending  force,  as  in  the  Barwell  sling. 
Or  the  body  may  be  bent  backward  upon  a  bent  frame,  as  in  the  one  used  by 
the  author,  or  in  the  much-used  prone  couch  of  Lonsdale.  The  frame  may 
be  so  arranged  that  the  patient  can  be  taken  into  the  open  air,  as  in  the  author's 
wheel  couch.  Or  the  patient  may  be  secured  to  a  wooden  frame  by  means 
of  plaster-of-Paris  bandages,  and  can  then  be  carried  about  from  place  to  place 
as  in  the  Phelps  plaster-of-Paris  portable  bed. 

Plaster-of-Paris  Splints. — The  plaster-of-Paris  bandage  should  be 
made  of  crinoline,  washed  or  unwashed,  or  gauze,  cut  into  bandages  of  different 
widths  varying  from  2  inches  to  6  inches,  and  the  plaster-of-Paris  thoroughly 


■ 

^■j 

■9 

1 

IP 

H 

^^'   / 

■*S^x 

CafiS 

dllH 

Mf~ 

^/ 

"^""Vl^y^itri 

„     .J'^ 

^n^^H 

n 

V-    ^ 

^yMfl|^^^HH 

m 

■ 

^H 

Fig.  129. — Author's  Traction  Plaster  Applied. 


Fig.  130. — Author's  Weight  and  Pulley  Bed  Traction  Applied. 


Fig.  131. — Freiburg  Extension. 


Fig.  132. — CoTTRELL  Dressing. 


Fig.  133.— Harwell's  Sling  (Hoffa). 


Fig.  134. — Author's  Bent  Bed  Frame. 


.Si«»«i"Si^^*?^^^        *-*'B,Sfe-_-_-^-^k. 

W 

i^rJi22i— -— «- — ^^^ 

M 

^ 

Fip.  135. — Author's  Wheel  Couch. 


Fig.  136. — Phelps'  Plaster-op-Paris  Portable  Bed  por  Hip-joint  Disease. 


Fig.    137. — Heine's   Plaster         Fig.   138. — Mikulicz's   Plaster      Fig.  139. — Vogt's  Plaster  Ban- 
Cast  (Schreiber).  Bandage  (Schreiber).  dage  with  Elastic  Traction 

(Schreiber). 


Fig.  140. — Ankle  Dressing  (Hoffa). 


Fig    141. — Knee  Extension  for  Plaster  Bandage  (Hoffa). 


Fig.  142. — Author's  Fkame  por  Applying  Spine  Cast. 


Fig.  143. — Author's  Frame  por  Applying  Spine  Cast,  showing  Frame  Ready  for  Use. 


Fig.  i44.^Author's  Frame  for  Applying  Spine  Cast,  showing  Patient  in  Position. 


">% 


Fig.  145. — Reed  Plaster  Cutter. 


Fig.  146.— Patient  Suspended  Ready  for  the 
Plaster  (Stimson). 


Fig.  147. — Suspensory  Apparatus  for  Applica- 
tion OF  the  Plaster  Jacket. 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


157 


rubbed  into  the  meshes  of  the  cloth.  The  bandages  should  be  softened  in 
water  containing  a  little  alum  and  salt.  They  should  be  stood  on  end  in 
sufi&cient  water  to  cover  them  and  be  allowed  to  remain  until  bubbles  cease 
to  rise,  when  they  should  be  squeezed  moderately  dry.  In  applying  the 
bandages  the  layers  should  overlap  about  two-thirds,  they  should  be  applied 

smootlily  without  being 
tight,  reverses  should  not 
be  used,  and  every  layer 
should  be  thoroughly  rubbed 


Fig.  148. — Celluloid  Support  for  Cervical  Caries. 


149. — Celluloid    Splint     for 
Knee-joint  Disease. 


into  the  preceding  layer.  Four  or  five  layers  will  be  found  sufficient  to  form 
a  very  firm  bandage  for  the  extremities,  and  six  to  eight  for  the  spine.  All 
prominences  should  be  well  padded. 

Plaster-of-Paris  jackets  may  be  applied  to  the  body  either  by  suspension, 
as  in  the  Sayre  suspension  apparatus,  or,  what  is  more  satisfactory,  especially 


158 


ORTHOPEDIC  SURGERY. 


for  children,  the  patient,  with  the  body  covered  by  a  closely  fitting  stockinet 
undervest,  is  placed  face  do-5\Tiward  upon  a  special  frame  made  of  gas-pipe 
to  which  canvas  or  unbleached  muslin  has  been  securely  attached,  and  the 

plaster-of-Paris  dressing  is  then  applied,  the  canvas  or  muslin  being  incor- 


FiG.  150. — Frame  for  Making  Spinal  Cuirass.j 


Fig.  151. — Stockinet  Applied. 


porated  into  the  dressing  and  afterward  removed.     The  manner  of  applying 
this  cast  is  weU  shown  in  the  author's  frame  for  applying  spine  casts. 

Celluloid  Splints. — Celluloid  is  of  late  being  extensively  used  for  the 
manufacture  of  splints.     A  thin  strip  of  celluloid  may  be  softened  in  hot  water 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


159 


and  applied  to  a  plaster-of -Paris  mold,  or,  preferably,  small  pieces  of  celluloid 
or^pyralin  may  be  dissolved  in  commercial  acetone  to  the  consistency  of  a  thick 


1 

jd^^ 

f 

""3 

9 

i  ^lyv- 

f    r' 

2^lB 

W^'^^  ■•^i 

m  ^  ..I 

^^^1 

'■'  \^ 

yiil 

hmI^^^^I 

H 

^gW^;' 

,^^^ 

^               ^^^H 

■ 

Pt, 

HH 

Fig.  152. — Plaster  Applied. 


syrup,  which  should  be  kept  in  a  tightly  closed  jar.  The  splint  is  made  by 
applying  five  or  six  layers  of  stockinet  successively  over  a  plaster-of-Paris 
model,  applying  after  each  layer  of  stockinet  four  or  five 
coatings  of  the  liquid  celluloid.  This  splint  should  not 
be  removed  from  the  model  for  four  days,  otherwise  it 
is  liable  not  to  retain  its  proper  shape.  At  the  end  of  this 
time  it  is 'split  anteriorly  and  a  light  coating  of  celluloid 
is  applied  to  the  inside.  The  edges  are  held  together  by 
means  of  leather  strips  containing  eyelets,  which  are  ap- 
plied to  the  edges  and  can  be  laced  together ;  or  else  straps 
with  buckles  attached  may  be  passed  around  the  splint 
at  intervals  of  four  or  five  inches  and  riveted  into  place. 
Felt  Splints. — Felt  splints  are  made  by  soaking  the 
material  in  a  saturated  solution  of  shellac  in  alcohol  and 
appl3dng  over  a  plaster-of-Paris  model.  Repeated  coat- 
ings of  the  shellac  and  alcohol  are  applied  untU  the  felt 
ceases  to  absorb.     After  twenty-four  hours  the  splint  can 

be  removed  from  the  model  and  finished.  It  is  usually  necessary  to  reinforce 
the  splint  with  strips  of  metal,  or,  what  is  preferable,  Russian  felt  which  has 
been  saturated  with  sizing  may  be  fitted  to  the  counter-cast  by  means  of  heat. 


Fig.  153. — Spinal  Cui- 
rass. 


160 


ORTHOPEDIC  SURGERY. 


A  felt  cuirass  for  use  in  cases  of  spinal  deformity  may  be  made,  and  may 
include  the  head,  neck,  and  trunk.  The  patient  is  placed  face  downward 
upon  a  specially  constructed  frame  covered  with  canvas.  Stockinet  is  applied 
to  fit  snugly  to  the  parts  which  are  to  be  included  in  the  cuirass  and  a  plaster- 
of- Paris  cast  is  applied.     From  this  an  exact  counter-cast  is  made,  and  over 


Fig.  154. — Silicate  of  Soda  Dressings  (Hoffa). 

I,  Paralysis  brace;  2,  knee  apparatus;  3,  hip  splint;  4,  artificial 
arm;  5,  corset;  6,  spine  brace. 


the  counter-cast  felt  is  fitted  by  means  of  heat  applied  with  a  tailor's  goose. 
The  head  portion  may  be  made  removable  from  the  body  portion  and  the 
entire  cuirass  should  be  reinforced  with  steel  bands.  It  should  be  perforated 
in  order  to  make  it  lighter  and  more  comfortable  in  the  warm  weather.  The 
cuirass  is  secured  to  the  body  by  broad  webbing  into  which  elastic  webbing 
has  been  incorporated,  and  a  frontal  band  and  shoulder-straps  complete  the 
apparatus. 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


161 


Silicate  of  Soda  Splints. — Silicate  of  soda  requires  considerable  time 
to  dry,  and  is,  on  this  account,  little  used  for  the  manufacture  of  splints.  It 
may  be  painted  on  with  a  brush  to  the  bandages  as  they  are  applied  to  the  part, 


Fig.     155. — Wooden     Corset, 

SHOWING  Layers. 

F,   Vertical  layers;    C,   reinforced 

layers. 


Fig.  156. — Section  of  Wooden  Corset. 

Stockinet; linen  batiste; 

wood;  B  B',  C  C,  overlapping  of  front 

and  back  layers. 


..-^      IL- 

FiG   157 — WiuAro  Hip  Splint       Fig.  i 58. — Marsh  Knee  Splint.      Fig.  159. — Marsh  Ankle  Splint. 


and  covered  for  a  day  with  a  light  plastcr-of-Paris  bandage,  or  they  may  be 
made  on  a  plaster-of-Paris  model.  The  edges  of  the  finished  splint  may  be 
laced  together. 

Paper  Splints. — Paper  is  used  to  some  extent  for  making  corsets  and 
12 


162 


ORTHOPEDIC  SURGERY 


splints  for  the  extremities.  These  are  made  by  first  applying  over  the  counter- 
cast  of  plaster  a  tight-fitting  gauze  stockinet  and  applying  the  paper  over  this 
in  thin  strips  fastened  together  with  the  best  quality  of  glue.  These  strips 
are  applied  in  a  manner  similar  to  that  used  in  manufacturing  corsets  of  wood, 
and  the  successive  layers  may  be  held  together  with  a  layer  of  fine  muslin. 
The  manufacture  of  these  splints  is  difficult  and  they  do  not  stand  the   heat 

as  well  as  leather  jackets,  but  they  are  lighter 
than  apparatus  made  of  any  other  material. 
Wood. — The  use  of  wood  in  the  manu- 
facture of  corsets  has  made  a  valuable  addi- 
tion to  orthopedic  armamentaria.  As  made  by 
Waltuch,  of  Odessa,  the  wooden  corset  consists 
essentially  of  a  wooden  cuirass  constructed 
somewhat  similarly  to  the  felt  and  leather 
jackets,  and  composed  of  alternate  layers  of 
stockinet,  wood,  roller  bandage,  and  linen  held 
intimately  together  with  glue.  For  its  manu- 
facture special  pine  or  fir  strips,  or  wood  ban- 
dages, are  employed.  Ordinary  plaster-of-Paris 
casts  are  not  adapted  to  the  preparation  of 
wooden  bandages,  since  they  are  very  brittle 
and  are  destroyed  by  the  pounding  and  ham- 
mering in  the  process  of  veneering,  but  Braatz 
models  are  very  firm,  being  made  of  a  mixture 
of  oakum  and  liquid  plaster.  The  layers  must 
be  applied  in  a  particular  order  so  as  to  secure 
strength.  This  is  well  shown  in  the  illustration 
(Fig.  156). 

Wooden  corsets  when  completed  do  'not 
weigh  more  than  one-third  as  much  as  the 
lightest  plaster-of-Paris  casts.  The  firmness 
of  the  wooden  corset  is  rendered  very  great  by  reason  of  the  crossing  of 
the  fibers  of  the  wooden  bandages.  It  is  somewhat  affected  by  the  heat 
of  summer,  but  not  so  greatly  as  are  felt  corsets,  nor  is  it  so  warm  as 
the  felt  or  leather.  Wooden  corsets  may  be  made  cooler  and  lighter  by 
perforations.  When  properly  made,  this  variety  of  orthopedic  appliance  is 
a  graceful  and  elegant  apparatus.     It  is  valuable  in   lumbar  Pott's  disease. 


Fig.  1 60. — Hessing  Leather  Appli 
ANCE  (Joachimsthal). 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


163 


as  a  cervical  collar  in  high  Pott's  disease,  or  as  a  retention  splint  in  knee-joint 
and  ankle-joint  disease. 

Leather. — Leather  splints  are  not  so  much  employed  as  formerly  because 
of  the  difficulty  in  obtaining  proper  material.  The  process  of  manufacture 
of  this  form  of  appliance  consists  of  three  parts — the  making  of  the  cast, 
the  making  of  the  counter-cast,  and  the  application  of  the  leather. 

In  making  the  cast  of  the  part, — for  example,  that  of  the  body, — the  cast 
is  applied  with  the  body  in  the  best  corrected  position,  a  tin  strip  being  used 
in  the  front,  upon  which  the  cast  may  afterward  be  cut  open.  Before  the  bq,n- 
dages  are  entirely  hard  the  front  of  the  cast  is  divided  upon  the  tin  strip  with 
a  very  sharp  knife,  and  it  is  then  removed  and  allowed  to  dry.     The  counter- 


FiG.  i6i. — Perforated  Leather  Jacket. 


Fig.  162. — Phelps'  Aluminum  Corset. 


cast  is  then  made  by  placing  the  cast  upon  a  board,  and  seaHng  it  up  the  front 
and  to  the  board  at  its  marginal  edges,  and  filling  it  with  liquid  plaster.  When 
this  has  hardened,  the  original  cast  is  removed,  and  the  counter-cast  may  be 
modeled  in  such  a  manner  as  to  improve  the  deformed  parts  and  permit  of  pres- 
sure by  the  apparatus  when  completed.  When  the  counter-cast  is  thoroughly 
dry,  the  leather  should  be  applied.  Rawhide  may  be  used,  but  half-tanned 
skin  or  leather  without  oil  or  dressing  will  be  found  most  useful.  This  should 
be  soaked  in  cold  water  for  twenty-four  hours  or  in  warm  water  for  one  hour. 
Before  applying  the  leather  to  the  counter-cast  two  tight-fitting  shirts 
should  be  applied,  and  the  leather  then  wrapped  about  it.  If  the  deformity 
is  very  great,  oblique  incisions  should  be  made  with  a  sharp  cobbler's  knife 
so  that  the  material  may  be  adapted  to  the  concavities.     The  wet  leather  is 


164  ORTHOPEDIC  SURGERY. 

fitted  to  the  cast  by  wrapping  about  it  a  tightly  wound  rope.  It  is  then  allowed 
to  become  thoroughly  dried,  and  is  finally  baked  in  an  oven,  after  which  it 
should  be  perforated,  trimmed,  and  bound,  and  it  may  be  finished  with  shellac 
or  fiesh-colored  enamel. 

If  raw  cow's  hide  is  used,  it  must  be  kept  in  lime-water,  and  may  be  pre- 
pared by  the  use  of  special  chemicals,  of  which  acetate  of  aluminum  is  the 
principal  one.     This  may  be  made  transparent  by  the  use  of  linseed  oil. 

Aluminum. — Aluminum  has  been  used  in  the  manufacture  of  corsets, 
and  when  this  material  is  used  it  is  necessary  to  make  it  in  two  parts,  front 
and  back,  or  two  lateral  parts,  which  can  be  fastened  together  with  a  hinge. 
It  is  beaten  into  shape  in  the  same  manner  as  repousse  brass  work,  and  may 
then  be  fitted  over  a  modeled  counter-cast. 

Artificial  Limbs. 

Artificial  limbs  are  employed  in  orthopedic  surgery  either  for  (i)  arrested 
growth  or  congenital  absence  of  parts,  or  (2)  after  amputations  which  have 
been  performed  for  disease  or  deformity. 

Surgeons  differ  as  to  the  proper  time  when  artificial  limbs  should  be  applied, 
since  a  certain  amount  of  time  must  be  allowed  for  the  natural  shrinkage  of 
the  part  and  before  the  cicatricial  tissue  will  permit  of  weight-bearing.  In 
most  instances  a  period  of  three  months  should  be  allowed  to  elapse  from  the 
time  of  the  amputation  before  attempting  to  fit  an  artificial  limb  properly. 

There  are  at  the  present  time  three  varieties  of  artificial  limbs  in  use — the 
old-fashioned  peg  leg,  a  hollow  appliance  made  of  willow  wood  and  having 
an  articulating  joint  at  the  ankle,  and  also  an  apparatus  of  the  same  nature 
with  the  addition  of  a  rubber  foot,  and  without  the  articulating  ankle-joint. 
In  Philadelphia  the  artificial  limbs  invented  by  Palmer,  and  later  manufactured 
by  Osborn,  Kolbe,  and  others,  are  appliances  characterized  by  durability,  light- 
ness, and  elegance  of  manufacture.  The  more  recent  addition  of  the  rubber 
foot  by  Marks,  of  New  York,  has  made  the  artificial  limb  nearly  perfect.  In 
fact,  so  closely  do  they  serve  the  purpose  of  the  natural  limb  that  individuals 
who  are  compelled  to  wear  them  often  feel  as  if  they  had  their  own  extremities 
beneath  them.  In  the  case  of  the  little  girl  illustrated  in  the  chapter  upon 
"Congenital  Absence  of  Parts"  the  artificial  apparatus  gave  her  the  sensation 
as  of  being  her  own  limbs. 

Artificial  limbs  should  be  so  constructed  as  to  receive  the  part  in  such 
a  manner  as  to  distribute  the  pressure  evenly  over  the  entire  surface,  so  that 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


165 


the  weight-bearing  does  not   rest   altogether  upon    the   extremity.      The    fit 
must  be  very  accurate  so  that  there  wiH  be  no  chafing  of  the  stump.      If  the 


Fig.  163.— Ordinary      Fig.^  164.— Improved     Fig    165.— Peg  Leg  for 
Peg  Leo.  Peg  Leg.  Amputation    below 

THE  Knee. 


A    A    MARKS, 


Fig.   166. — .'^RTiPiciAL  Limb  for 
.''i.NKLE-joiNT  Amputation. 


Fig.   167.— Artificial  Limb 
for  Foot  Amputation. 


fit  be  accurate,  a  certain  amount  of  slipping  of  the  stump  is  desirable.     Artifi- 
cial limbs  are  sometimes  made  water-proof  so  that  persons  requiring  them  may 


166 


ORTHOPEDIC  SURGERY. 


be  enabled  to  pursue  occupations  where  it  may  be  necessary  to  stand  in  damp 
places,  or  so  that  they  may  indulge  in  trout-fishing,  aquatic  sports,  etc.     The 


Fig.    1 68. — Artificial  Limb  foe  Knee-joint 
Amputation. 


Fig.  i6g. 


-Artificial  Limb  for  Amputation 

BELOW    THE    KnEE. 


use  of  the  rubber  foot  is  a  decided  advantage,  since  there  is  no  mechanism  at 
the  ankle-joint  to  get    out    of  order  and  the  weight  is  transmitted  to  the 

ground    with    greater    precision    and 
security. 

In  the  choice  of  amputation  the 
orthopedic  surgeon  has  a  decided  ad- 
vantage over  the  general  surgeon,  since 
in  most  conditions  requiring  amputa- 
tion in  the  field  of  orthopedics  the  parts 
are  not  devitalized  by  traumatism.     In 
amputations  of  the  thigh  it  is  best  to 
leave    the    stump    as  long    as  possible  in  order    to   increase    the  leverage, 
whereas    in    amputations    of    the   leg   it   has   been   found   that    amputations 
in    the   middle   or    upper    third    of  the    leg  are  better  adapted    to   the  use 


Fig.  170. — Rubber  Foot. 


Fjg.  171. — Manipulation  roE  Ankylosis  of  Shoulder. 


Fig.  172. — Manipulation  foe  Ankylosis  of  Elbow. 


Fig.  173. — Manipulation  por  Ankylosis  of  Knee — Flexion. 


Fig.  174. — Manipulation  for  .'Ankylosis  of  Knee — Extension. 


PROPHYLAXIS  AND  GENERAL  TREATMENT.  171 

of  artificial  apparatus.  In  amputations  of  the  foot  so  much  difficuhy  has 
been  experienced  in  fitting  artificial  apparatus  that  there  has  been  a  ten- 
dency among  surgeons  to  perform  amputations  through  the  leg.  This 
should  be  avoided,  since  many  of  the  deformed  conditions  following  partial 
amputations  of  the  foot  can  be  readily  fitted  with  orthopedic  shoes  or  with 
some  appliance. 

The  use  of  orthopedic  apparatus  for  deformities  resulting  from  arrest 
of  growth  or  congenital  absence  of  parts  partakes  of  the  nature  of  artificial 
limbs,  and  in  many  instances  a  properly  fitting  artificial  limb  will  answer,  every 
purpose.  If  the  deformed  limb  is  only  slightly  shorter  than  its  fellow,  the 
deficiency  may  be  made  up  by  a  properly  constructed  shoe,  or  by  the  addition 
of  cork,  aluniinum,  etc.,  to  the  shoe.  If  the  deformed  member  extends  only 
as  far  as  the  knee,  the  part  can  be  encased  in  an  artificial  limb,  the  foot  resting 
over  the  joint  of  the  artificial  appliance.  If  the  lower  extremity  is  entirely 
wanting,  an  artificial  limb,  the  same  as  used  in  cases  of  amputation,  may  be 
applied  at  the  hip-joint.  In  this  instance  it  will  be  necessary  to  have  at  the 
knee  a  locking  and  unlocking  joint  in  order  to  afford  stability  in  walking. 
When  both  lower  extremities  are  wanting,  an  apparatus  such  as  is  shown  in 
the  chapter  upon  " Congenital  Absence  of  Parts"  will  be  found  of  use. 

Orthopedic   Operations. 

Operations  performed  by  the  orthopedic  surgeon  may  be  comprised  under 
the  two  heads  of  bloodless  or  forcible  correction,  and  those  performed  with  the 
knife. 

Forcible  Correction. — This  method  of  correcting  deformity  is  extensively 
used  in  orthopedic  surgery  for  making  correction  in  such  affections  as  club- 
foot, torticollis,  dislocation  of  the  hip,  bow-legs,  and  ankylosed  joints.  The 
force  may  be  applied  by  means  of  the  hands,  when  it  is  spoken  of  as  manual 
correction;  or  it  may  be  accomplished  by  the  aid  of  machines,  when  it  is 
spoken  of  as  mechanical  correction.  The  complete  correction  is  sometimes 
accomplished  by  force  or  it  is  sometimes  applied  after  cutting  operations  have 
been  performed. 

Corrective  manipulations  are  especially  valuable  in  cases  of  ankylosed 
joints.  A  soft  thick  pad  should  be  applied  in  such  a  manner  as  to  allow  the 
joint  to  be  free.  The  operator  holds  the  joint  so  as  to  protect  the  epiphysis 
from  injury,  and  by  gradual  flexions  and  extensions  breaks  up  the  adhesions 
and  restores  the  function  of  the  part.     Manipulations  of  this  kind  are  exten- 


172 


ORTHOPEDIC  SURGERY. 


sively  employed  in  ankylosis  of  the  shoulder,  elbow,  knee,  and  ankle.  Where 
greater  force  is  required  than  can  be  accomplished  with  the  hand,  special 
machines  are  used,  as  the  Goldthwaite  machine  for  ankylosis  of  the  knee  or  the 


Fig.  175. — Goldthwaite  Machine  for  Correc 
HON  of  Ankylosis  of  Knee  Applied. 


Fig.  176. — Goldthwaite  Machine  for  Correc- 
tion OF  .Ankylosis  of  Knee. 
A,  Screw;  B,  steel  band;  C,  pressure  plate;  D,  E,  counter-pressure  straps;  F,  leg  strap. 


Thomas,  McKenzie,  and  Gibney  club-foot  wrenches.  When  properly  applied 
an  enormous  amount  of  force  may  be  e.xerted  without  injury  to  the  part, 
the  Phelps  machine  for  the  correction  of  club-foot  being  capable  of  applying 
pressure  to  the  amount  of  2000  pounds. 


Fig.   177. — McKenzie  Club-foot  Wrenxh. 


Osteoclasis,  or  forcible  fracture  of  bones  by  means  of  instruments,  has  been 
much  employed  of  late,  both  abroad  and  in  this  country,  for  rachitic  and  other 
deformities  of  the  lower  extremities.     This  method  of  correction  is  more  appli- 


PROPHYLAXIS  AND  GENERAL  TREATMENT. 


173 


cable  to  the  shaft  of  the  bone,  as  in  bow-legs,  in  which  locality  it  is  slightly 
safer  than  osteotomy.  The  objections  to  this  method  are  the  lack  of  pre- 
cision and  the  liability  of  the  splintering  of  the  fragments,  the  rupture  of  the 


Fig.  178. — Thomas  Club-foot  Wrench. 


Fig.  179. — Same  Applied. 


Fig.  180. — Collins  Osteoclast. 


ligaments,  and  the  separation  of  the  epiphysis;  but  these  objections  are  more 
theoretic  than  real,  and  when  properly  applied  and  skilfully  used  it  is  a  very 
valuable  method  of  correction. 

Excellent  osteoclasts  have  been  invented  by  Collin,  Lorenz,  Robin,  Grat- 


174  ORTHOPEDIC  SURGERY. 

tan,  and  the  one  which  the  writer  has  employed  for  some  years,  that  invented 
by  Rizzoli.  The  term  "rapid  osteoclasy"  has  been  appHed  to  the  method 
as  performed  by  Blanchard  with  the  Grattan  osteoclast.  He  reports  262  cases 
of  rachitic  deformities  corrected  by  rapid  osteoclasty  and  osteokampsis  without 


Fig.  iSi. — Geattan  Osteoclast. 


a  single  injury,  abrasion  of  the  soft  parts,  or  epiphyseal  separation.  The  ages 
varied  from  four  to  sixteen  years,  the  average  being  seven  years  and  nine 
months.  The  compression  time  in  the  osteoclast  did  not  exceed  eight  seconds, 
and  the  entire  time  for  the  details  of  the  operation  seldom  exceeded  six  minutes. 


Fig.  1S2. — Rizzoli  Osteoclast. 

The  operation  of  osteoclasy  should  not  be  performed  before  four  years 
of  age,  and  the  best  time  is  the  sixth  year. 

The  technic  with  the  Grattan  osteoclast  is  as  follows:  In  breaking  the 
tibia  in  the  middle  of  its  shaft  the  limb  is  firmly  fixed  by  the  hands  of  an  assist- 
ant in  such  a  position  that  the  central  portion,  or  plunger,  will  strike  upon  the 
most  prominent  portion  of  the  deformity,  the  lower  and  upper  resistant  bars 


PROPHYLAXIS  AND  GENERAL  TREATMENT.  175 

being  placed  at  such  a  distance  from  each  other  as  to  allow  the  fracture  to 
occur  and  not  to  encroach  upon  the  epiphysis  at  either  extremity  of  the  tibia. 
In  using  this  instrument  for  knock-knee  the  lower  resistant  bar  is  placed  over  the 
external  condyle  and  the  upper  resistant  bar  is  separated  about  four  inches. 
The  limb  is  securely  held  by  the  hands  of  an  assistant  and  the  breaking  bar 
is  rapidly  screwed  down  so  as  to  break  or  bend  the  bone  at  the  point  selected. 

In  using  the  Rizzoli  osteoclast  for  correcting  bow-leg  in  the  tibia  the  limb 
should  be  rendered  thoroughly  aseptic,  as  for  a  cutting  operation,  and  should 
be  bound  securely  in  gauze  compresses  and  a  towel.  The  limb  is  placed  through 
rings  which  are  separated  as  widely  as  possible  without  resting  upon  the  epiphy- 
sis, and  the  plunger  is  applied  over  the  inner  surface  so  as  to  strike  the  point 
of  greatest  convexity.  After  the  fracture  has  been  accomplished  the  limb  is 
dressed  in  gauze,  a  flannel  or  gauze  roller  is  applied  to  the  limb,  and  while  it 
is  held  in  a  sHghtly  overcorrected  position  a  plaster-of-Paris  dressing  is  ap- 
plied. Before  this  has  entirely  hardened  it  should  be  divided  upon  a  tin  strip 
with  a  sharp  knife,  or  if  it  has  hardened  it  may  be  divided  with  a  plaster  cutter. 

The  Lorenz  osteoclast  is  employed  to  correct  deformity  in  the  neighborhood 
of  the  joint.  The  ligaments  are  stretched,  the  shaft  of  the  bone  is  bent,  and 
in  some  instances  actual  separation  and  displacement  of  the  epiphysis  occurs. 
The  operation  is  always  performed  under  anesthesia,  and  afterward  the  limb  is 
secured  in  an  overcorrected  position  in  plaster-of-Paris  dressings. 


CHAPTER  VI. 
TENOTOMY. 

Two  principal  methods  of  tenotomy  are  in  general  use,  the  subcutaneous 
and  the  open  operation.  The  former  method  is  still  employed  in  certain 
localities,  as  in  lengthening  the  tendo  Achillis,  and  the  latter  method  is  employed 
wherever  it  is  considered  safer  to  expose  the  tendon  and  avoid  injury  to  the 
adjacent  structures. 

The  term  tenotomy  embraces  tenorrhaphy,  or  the  lengthening  or  shorten- 
ing of  tendons,  tendon  transplantation,  sometimes  spoken  of  as  musculo-tendin- 
ous  anastomosis,  and  tenoplasty. 

A  tendon  may  be  lengthened  by  transverse  section,  the  separation  of  the 
parts  being  accomplished  by  the  muscle  tonicity  or  by  the  stretching  of  the 
part. 

According  to  Wilson,  tendon  splicing  was  first  suggested  by  Rhoads,  of 
Philadelphia,  was  first  performed  ■  by  Anderson,  and  was  first  described  by 
Keen. 

The  dividing  or  splitting  of  a  tendon  may  be  done  by  making  either  a  longi- 
tudinal or  an  oblique  section.  When  the  longitudinal  section  is  used,  the  upper 
and  lower  portions  of  the  tendon  must  be  divided  by  a  sagittal  or  cross-cut, 
from  the  longitudinal  incision  outward  or  from  the  inside  out  to  the  longitudinal 
cut,  thus  making  a  Z-shaped  section. 

Since  this  method  was  first  performed  by  Anderson,  it  is  known  as  the  Ander- 
son method. 

This  operation,  as  first  performed  for  "contractions  of  the  fingers  and  toes," 
was  as  follows:  A  large  curved  incision  is  made  through  the  skin  and  super- 
ficial fascias  over  the  tendons  to  be  lengthened.  The  tendons  are  lifted  up 
individually  upon  a  grooved  director,  split  longitudinally,  and  the  ends  are 
cut  out  on  either  side  and  are  slid  past  each  other,  great  care  being  taken  to 
keep  the  cut  surfaces  in  contact.  They  are  then  stitched  together  with  fine 
chromicized  catgut,  the  fascias  and  skin  are  brought  together  with  catgut, 
and  the  part  is  put  in  a  deformed  position  until  healing  has  occurred. 

A  modification  of  this  method,  described  as  a  subcutaneous  operation, 

176 


TENOTOMY. 


177 


is  credited  to  Bayer.     As  first  described  by  him,  the  operation  was  performed 

through  an  open  wound,  and  while  the  tendon  was  not  lifted  out,  it  would  not 

now  be  considered  a  subcutaneous  operation.     His  subsequent  operation  may  be 

described  as  follows:     Two  points  are  marked 

upon  the  skin  which  indicate  the  termination  of 

the  length  of  the  incision,  a  small  tenotome  is 

introduced   subcutaneously  into  the  middle  of 

the  tendon  and  it  is  divided  longitudinally  from 

behind  forward  or  from  before  backward.     The 

ends  are  divided  and  the  cut  surfaces  are  slid 

past  each  other. 

A  modification  of  the  Anderson  open 
method  has  been  devised  by  Rugh,  of  Phila- 
delphia. It  consists  in  inserting  a  small  split- 
ting knife  through  an  incision  one-half  to 
three-fourths  of  an  inch  in  length.  The 
tendon  is  then  divided  for  a  distance  of  from 

two  to  three  inches,  the  knife  is  withdrawn  in  the  same  line  and  pushed 
in  the  opposite  direction  the  same  distance,  splitting  the  tendon  for  from 
four  to  six  inches.  The  upper  and  lower  ends  of  the  tendon  incision 
are   marked    upon    the    skin   with   a   sharp-pointed    tenotome,  and    after  the 


Fig.  183. — Author's  Tenotomes. 
Straight,  blunt-pointed;  2,  straight, 
sharp-pointed;  3,  convex,  sharp- 
pointed;  4,  convex,  probe-pointed; 
5,  straight,  probe-pointed,  long  cut- 
ting face;  6,  straight,  probe-pointed, 
short  cutting  face. 


-Tenotomy  after  Bayer  (Joachims-      Fig.  185. — Bayer's  Sdbcut.aneous  Tenotomy  (Toachimsthal). 
thai). 


withdrawal  of  the  splitting  knife  the  tenotome  is  introduced  on  one  side  of 
the  tendon  and  on  the  other  side  at  the  other  end,  and  the  tendon  is  slowly 
divided  down  to  the  longitudinal  slit.  The  ends  are  slid  past  each  other  the 
desired  length  and  are  sewed  together  through  the  skin  incision  and  the  in- 
cision is  closed  with  catgut  sutures. 

13 


178  ORTHOPEDIC  SURGERY. 

The  advantages  claimed  for  this  operation  are  the  short  skin  incision,  and 
the  lessened  danger  of  sepsis  and  of  sloughing.  There  is  one  objection  to 
this  and  the  Bayer  method;  that  is,  where  the  tendon  is  twisted.  When  this 
condition  is  encountered,  the  tendon  cannot  be  divided  subcutaneously,  and 
the  Anderson  operation  has  to  be  performed. 

The  tendon  may  also  be  divided  higher  than  the  usual  section,  cutting 
through  the  tendon  into  the  muscular  portion,  so  that  as  the  deformity  is  cor- 
rected the  tendon  remains  in  partial  contact  with  the  cut  muscle,  or  a  number 
of  small  notches  may  be  made  at  different  points  along  the  side  of  the  tendon. 

Immediately  following  a  well-performed  operation  of  lengthening  a  tendon 
a  process  of  regeneration  begins  by  the  effusion  of  a  fluid  or  semi-fluid  lymph 
exudate  from  the  peri-tendineum  internum  and  externum.  A  very  little  blood 
is  effused  into  the  space  from  which  the  upper  part  of  the  tendon  has  been 
retracted.  If  much  blood  has  been  effused,  it  retards  the  formation  of  the 
proper  exudate.  The  adjacent  blood-vessels  enlarge  and  the  tissues  about  the 
wound  become  infiltrated,  yellow,  and  succulent.  This  exudate  takes  no  part 
in  the  reparative  process,  and  usually  ceases  in  twenty-four  hours.  Somewhat 
later — three  to  seven  days — the  proper  reparative  material  makes  its  appearance 
(the  inflammatory  exudate  ceases  or  degenerates)  and  fills  the  entire  space 
between  the  divided  extremities  of  the  tendon  and  unsheaths  them  both  for  a 
short  distance.  The  stumps  of  the  cut  tendons  swell,  and  microscopically 
many  mitoses  may  be  seen  both  in  the  central  and  peripheral  areas.  Fine 
young  tendon  fibers  are  gradually  diff'erentiated  into  bundles  of  connective 
tissue.  This  gradually  becomes  firmer,  stronger,  and  grayer,  and  forms  a 
distinct  bond  of  union  between  the  ends  of  the  tendon.  The  differentiation 
gradually  advances,  at  first  rapidly,  later  more  slowly,  in  time  becoming 
identical,  even  microscopically,  with  the  original  tendon. 

Adams  in  his  dissected  cases  showed  that  the  tendon  and  sheath  at  the 
point  of  section  had  almost  entirely  returned  to  its  normal  condition,  and  could 
scarcely  be  detected  on  the  closest  scrutiny ;  and  Sir  James  Paget  says,  in 
referring  to  the  specimens  of  tendo  Achillis,  posterior  and  anterior  tibial  tendons, 
deposited  by  Tamplin  in  the  INIuseum  of  the  Royal  College  of  Surgeons,  which 
had  been  divided  four  months  before  death,  that  "no  trace  of  division  of  any 
of  the  tendons  could  be  detected  even  with  microscopic  aid." 

There  is,  however,  in  all  instances  a  diff'erence  in  the  separability  of  the 
sheath  of  the  divided  tendon  over  the  seat  of  the  previous  operation,  if  the 
dissection  be  carried  from  above  downward  or  from  below  upward. 


TENOTOMY.  179 

Of  late  years  the  method  of  immediate  restoration,  and,  in  fact,  of  slight 
over-correction,  after  tenotomy  is  the  one  usually  adopted  by  all  practical  sur- 
geons. Under  these  circumstances  it  is  very  interesting  to  observe  that  this 
reparative  exudate  is  always  sufficient  to  fill  the  space  between  the  severed  ends, 
which  in  some  instances  is  very  great.  In  a  case  related  to  me  by  Prof.  Willard 
the  ends  were  separated  three  inches  and  firm  union  occurred.  The  most 
interesting  feature  of  the  process,  however,  and  the  one  bearing  directly  upon 
the  subject  of  over-correction,  is  that  brought  out  by  some  investigations  of 
the  writer  upon  rabbits,  which  demonstrated  conclusively  that  if  the  ends  of 
a  divided  tendon  be  separated  a  very  short  distance,  but  a  small  amount  of 
exudate  fills  the  space;  if  they  be  separated  a  great  distance,  the  entire  space 
is  filled  in;  and  if  they  be  separated  at  first  but  a  short  distance,  or  the  ends 
remain  in  contact,  and  are  subsequently  separated,  the  resulting  tendon  will  be 
a  weakened,  spindle-shaped  one,  from  the  stretching-out  of  the  plastic  exudate. 

Technic. — In  performing  subcutaneous  tenotomy  much  of  the  success 
depends  on  the  technic.  If  the  pointed  tenotomes  be  employed,  as,  for 
example,  the  slightly  sickle-shaped  knife  of  Dieffenbach,  no  other  instrument 
is  needed;  but  if  blunt,  rounded  tenotomes  are  used,  another  sharp-pointed 
bistoury  must  be  employed  for  the  puncture  of  the  skin,  and  this  is  always 
a  disadvantage,  but  one  that  cannot  be  overcome  in  certain  localities.  Teno- 
tomes are  best  made  in  sets  of  six  or  eight,  the  cutting  surface  of  the  largest  of 
which  should  not  exceed  an  inch  in  length  and  one-fourth  of  an  inch  in 
breadth.  They  should  be  made  of  one  piece  of  metal,  nickel-plated,  strong 
in  the  shank  to  avoid  the  danger  of  breaking  off  in  the  wound;  and  a  set  of 
this  kind  should  include  one  or  two  pointed  knives  with  rounded  bellies  for 
cutting  small  superficial  tendons,  and  one  pointed,  flat-bellied  tenotome  with 
long  cutting-face  for  cutting  the  plantar  fascia.  Anesthesia  is  not  absolutely 
essential,  owing  to  the  short  time  required  for  the  operation,  but  is  usually 
employed  to  overcome  movements  on  the  [part  of  the  patient  which  might 
interfere  with  the  operation. 

The  day  before  the  operation  the  skin  should  be  rendered  aseptic  by  a 
careful  cleansing  with  green  soap  and  water,  a  thorough  washing  with  i :  looo 
bichlorid  solution,  and  a  wet  compress  should  be  applied  for  twelve  hours. 
Immediately  before  the  operation  it  should  be  again  prepared  by  washing  the 
part  with  green  soap  and  sterile  water,  either  with  a  skin-brush  or  with 
gauze  sponges.  It  should  then  be  washed  with  alcohol,  to  be  followed  by 
a  solution  of  i :  looo  bichlorid  of  mercury.      It  should   then   be   dried  with 


180  ORTHOPEDIC  SURGERY. 

gauze  sponges  and  the  surface  washed  with  ether.  All  callus  should  be 
removed  from  the  feet  before  the  operation,  as  this  would  make  pain- 
ful pressure  beneath  the  dressing.  In  some  instances  where  the  skin  is  very 
thick,  or  discolored,  or  foul,  it  should  be  prepared  for  several  days  previoils 
to  the  operation  by  applying  first  a  saturated  solution  of  permanganate  of  potash 
for  three  minutes,  followed  by  a  saturated  solution  of  oxalic  acid  for  the  same 
length  of  time,  after  which  the  preparation  before  described  may  be  used.  The 
aseptic  preparation  of  the  part  should  be  very  carefully  carried  out,  particularly 
where  the  open  operation  is  performed. 

The  surgeon's  hands  should  be  very  carefully  prepared  by  washing 
thoroughly  with  soap  and  water,  using  a  hand-brush;  the  nails  should  be 
carefully  cleaned  and  the  hands  dipped  in  alcohol.  They  should  then  be  held 
for  three  minutes  in  a  saturated  solution  of  permanganate  of  potash  and  for 
three  minutes  in  a  saturated  solution  of  oxalic  acid,  and  then  be  thoroughly 
washed  in  a  solution  of  i :  looo  bichlorid  of  mercury,  and  finally  washed  in 
sterile  water,  in  which  the  rubber  gloves  should  be  put  on. 

The  skin  having  been  previously  rendered  aseptic  as  described  above,  the 
parts  are  so  held  as  to  render  the  shortened  tendons  prominent.  The  skin 
over  the  tendon  is  then  punctured  about  its  middle  in  such  a  manner  that  this 
incision  and  the  one  in  the  deeper  parts  shall  not  correspond  when  the  parts 
are  relaxed.  The  tenotome  is  carried  flatwise  beneath  and  close  to  the  under 
surface  of  the  tendon,  the  cutting-edge  is  turned  against  it  and  the  division 
accomplished  by  a  slight  rocking  motion.  The  section  is  usually  evidenced 
by  an  audible  crackling  and  the  extension  of  the  contracted  part.  The  assistant 
should  at  once  relax  the  part.  The  tenotome  is  then  turned  flat  and  with- 
drawn, the  operator  compressing  the  wound  to  prevent  any  ingress  of  air.  The 
puncture  is  dusted  with  acetanilid  or  thymol  iodid,  dressed  with  a  small  wet 
bichlorid  compress,  and  by  a  superficial  dressing  of  gauze  and  cotton,  and 
a  prepared  or  flannel  roller.  The  parts  should  then  be  placed  in  a  slightly 
over-corrected  position  and  retained  in  position  by  a  metal  retention-shoe  which 
allows  inspection,  or  a  plaster  dressing.  The  wound  need  not  be  inspected  for 
ten  days  unless  pain  or  elevation  of  temperature  calls  attention  to  the  part. 

Complications  of  Tenotomy. — Owing  to  the  prominence  of  the  con- 
tracted tendons  there  is  not  the  same  difficulty  there  would  be  in  the  normal 
state,  and  not  the  same  danger  of  wounding  adjacent  structures,  hence  the 
complications  following  tenotomy  are  therefore  few  and  usually  slight.  There 
may  be: 


TENOTOMY.  181 

1.  Too  great  wound  in  the  tissues  or  puncture  of  the  opposite  side  from 
movements  of  the  patient.  With  an  antiseptic  dressing  such  accidents  are 
of  no  importance. 

2.  Profuse  hemorrhage  from  wounding  a  large  artery,  as  the  anterior 
or  posterior  tibial  or  plantar  fascia,  is  sometimes  alarming,  but  calls  for  an 
antiseptic  compress,  a  ligature  being  seldom  necessary.  Such  an  accident 
can  usually  be  avoided  by  inserting  the  tenotome  in  such  a  manner  as  to  avoid 
the  artery,  and  then  cutting  away  from  it.  For  this  reason,  in  section  of  the 
tendo  Achillis,  if  a  sharp-pointed  tenotome  be  employed  the  puncture  should 
be  made  on  the  inner  side  to  avoid  the  risk  of  wounding  the  posterior  tibial 
artery  with  its  point. 

3.  A  traumatic  aneurysm  may  be  treated  with  a  firm  compress  or  the 
vessel  may  be  ligated. 

4.  The  section  of  a  nerve,  which,  although  a  disagreeable  complication, 
calls  for  no  special  concern,  as  the  ends,  if  sutured,  will  probably  unite  in 
a  short  time. 

5.  Incomplete  section  of  a  tendon,  which  should  be  guarded  against  by 
observing  that  the  tendon  is  completely  severed  before  the  tenotome  is  with- 
drawn. Otherwise  the  operator  must  forcibly  rupture  the  undivided  fibers 
or  reinsert  the  knife. 

6.  Suppuration,  which  very  rarely  occurs,  but  should  be  met  by  free  drain- 
age and  antiseptic  dressings. 

7.  The  non-union  of  a  divided  tendon  is  an  exceedingly  rare  occurrence, 
but  one  which  may  happen.  Adams  reports  having  witnessed  it  once,  and 
this  where  the  tendon  had  been  divided  in  a  situation  not  usually  selected  by 
orthopedic  surgeons.  The  possibility  of  such  an  occurrence  should  be  avoided 
by  selecting  in  all  cases  the  proper  locality  for  section. 

While  experience  confirms  the  truth  of  the  statement  that  the  accidents 
of  tenotomy  are  few  and  usually  slight,  these  operations  are  not,  however,  en- 
tirely free  from  dangerous  complications.  Thus,  Agnew  records  the  fact  that 
he  has  seen  death  from  erysipelas  follow  the  division  of  the  adductor  longus 
tendon  at  its  origin;  has  known  a  child  to  perish  from  concealed  hemorrhage 
after  an  operation  for  club-foot,  and  has  seen  a  leg  rendered  useless  in  a  great 
measure  from  section  of  the  peroneal  nerve  during  tenotomy  of  the  outer  ham- 
string. 

The  individual  tendons  most  frequently  requiring  division  by  the  sub- 
cutaneous  method  are  the  tendo   Achillis,   the    tibialis   anticus,    the   plantar 


182 


ORTHOPEDIC  SURGERY. 


fascia,  the  peroneal  tendons,  and  the  inner  hamstring;  and  those  by  the 
open  method  are  the  sternocleidomastoid,  the  outer  hamstring,  and  the  tibialis 
posticus. 

Division  of  the  Tendo  Achillis. — In  dividing  this  tendon  the  patient, 
etherized,  is  placed  upon  the  breast  or  side;  an  assistant  renders  the  tendon 
moderately  tense  by  flexing  the  foot.  The  puncture  is  then  made  with  the 
sharp-pointed  tenotome,  about  one  inch  above  its  insertion,  a  short  distance 
from  the  tendon  to  be  divided,  and  preferably  to  the  outer  or  fibular  side,  to 
avoid  injury  of  the  posterior  tibial  artery.     The  blunt-pointed  tenotome  is  then 


Fig.  iS6. — Making  PuNCTtTRE  for  TENOxoiiY  of  Tendo  Achillis. 


inserted  into  the  puncture  flatwise,  and  carried  behind  the  tendon  as  close 
as  possible  to  its  posterior  surface;  the  edge  is  then  turned  against  the  tendon, 
and  by  a  slightly  rocking,  not  a  swinging,  motion  the  tendon  is  divided,  care 
being  taken  not  to  divide  the  skin  nor  to  enlarge  the  puncture  wound.  The 
division  of  the  tendon  is  evidenced  by  a  sensible  and  audible  snap,  the  suik- 
ing-in  of  the  soft  parts  and  the  extension  of  the  heel.  The  assistant  should 
at  once  relax  the  parts  immediately  the  section  is  accomplished.  The  knife 
is  then  turned  flat  and  withdrawn,  pressure  being  made  with  the  finger  to 
prevent  the  ingress  of  air.     The  parts  are  then  dressed  as  before  given. 


TENOTOMY. 


183 


The  writer  has  twice  met  with  quite  a  severe  hemorrhage  in  dividing  the 
tendo  Achillis,  once  in  an  infantile  case  and  once  in  a  young  adult  who  had  been 
previously  operated  upon.  It  appeared  to  come  from  a  small  unnamed  artery 
which  supplies  the  sheath  of  the  tendon,  and  was  in  each  case  readily  con- 
trolled by  a  firm  compress.  An  attempt  should  always  be  made  to  control 
even  the  slightest  amount  of  bleeding  from  tenotomy,  lest  the  blood-clot  in 
the  sheath  interfere  with  the  normal  healing  process. 

Division   of  the   Tibialis  Anticus  Tendon. — This   tendon   is   divided 


Fig.  187. — Dividing  the  Tendo  Achillis. 


about  two  inches  above  its  insertion,  the  points  for  its  division  being  found 
from  the  prominence  of  the  tendon  on  the  inner  aspect  of  the  foot  a  short  dis- 
tance above  the  scaphoid  tubercle.  In  many  cases  the  puncture  used  for  divid- 
ing this  tendon  wiU  also  answer  for  the  division  of  the  plantar  fascia.  For  the 
division  of  this  tendon  a  sharp-pointed  tenotome  alone  will  sufiSce.  The  knife 
is  inserted  beneath  the  tendon,  its  edge  turned  upward,  and  division  easily 
accomplished,  care  being  taken  to  avoid  wounding  the  skin. 

Division  of  the  Plantar  Fascia. — This  fascia  is  divided  at  its  most  promi- 
nent point.     A  sharp  tenotome  alone  may  be  employed,  or  if  the  division  is  to 


1S4  ORTHOPEDIC  SURGERY. 

be  extensive  a  blunt  tenotome  will  be  preferable.  The  puncture  used  for  the 
section  of  the  anterior  tibial  tendon  may  be  employed,  or  a  new  puncture  may 
be  made  in  the  inner  side  of  the  sole  of  the  foot  nearly  midway  between  the 
OS  calcis  and  the  ball  of  the  great  toe,  but  a  little  nearer  the  os  calcis.  The 
knife  is  carried  close  to  the  fascia  flatwise  between  it  and  the  skin,  the  blade 
is  turned  toward  the  sole  of  the  foot,  and  the  section  accomplished.  In  infan- 
tile cases  it  is  advisable  to  make  but  small  sections  at  one  time,  repeating  these 
if  necessary.  Should  the  internal  plantar  artery  be  completely  divided,  it  will 
not  complicate  the  operation ;  but  if  it  be  wounded  in  division  of  the  plantar 
fascia,  a  few  days  should  elapse  before  instituting  restitution  and  extension, 
lest  aneurysm  result. 

Division  of  the  Peroneal  Tendons. — If  the  slightly  sickle-shaped  knife 
be  employed,  no  other  instrument  is  needed;  but  if  a  probe-pointed  tenotome 
be  used,  another  sharp-pointed  instrument  must  be  employed  to  puncture  the 
skin.  Anesthesia  is  not  absolutely  necessary,  and  in  dividing  this  tendon  the 
writer  usually  employs  local  freezing  with  ice  and  salt.  The  parts,  rendered 
aseptic  and  insensible,  are  held  in  a  position  which  renders  the  affected  tendons 
prominent.  A  puncture  having  been  made  a  short  distance  behind  the  external 
malleolus,  so  that  it  will  not  correspond  with  the  one  in  the  deeper  tissues  when 
the  parts  are  relaxed,  the  blunt-pointed  tenotome  is  passed  either  over  the  ten- 
dons, between  them  and  the  skin,  and  the  division  of  the  constricted  tendons 
accompHshed  by  cutting  directly  down  upon  the  external  malleolus,  or,  as  the 
writer  prefers,  the  tenotome  is  passed  beneath  the  tendons  and  the  cut  is  made 
directly  outward,  care  being  taken  not  to  cut  the  skin  nor  increase  the  size  of 
the  puncture.  The  proper  division  of  the  tendons  is  evidenced  by  an  audible 
crackling  and  the  fact  that  the  foot  now  remains  in  its  normal  position.  The 
tenotome  is  then  turned  flatwise  and  withdrawn;  the  operator,  compressing 
the  wound  to  prevent  the  ingress  of  air,  places  an  antiseptic  dressing  upon  the 
part,  and  secures  it  in  position  with  a  plaster-of-Paris  bandage.  Over-correc- 
tion is  not  necessary  in  these  cases,  as  relapse  is  not  so  likely  to  occur  as  after 
the  section  of  contracted  tendons. 

Division  of  the  Inner  Hamstring  Tendons. — The  division  of  these 
tendons  in  adults  may  ordinarily  be  accomplished  by  subcutaneous  tenot- 
omy. The  tendons  should  be  located  with  the  finger  about  an  inch  from 
their  insertion  and  the  puncture  should  be  made  with  a  sharp  tenotome  and 
the  division  made  with  a  blunt-pointed  tenotome  inserted  from  within  outward. 
If  the  deformity  is  very  great,  it  is  always  safer  to  make  an  open   section; 


Fig.  iSS. — Superpicial  Structures  of  the  Neck  (Deaver). 
Showing  relations  of  sternomastoid  muscle. 


TENOTOMY. 


187 


and  if  there  is  any  doubt  about  the  exact  position  of  the   tendons  on  account 
of  their  displacement,  it  is  much  safer  to  expose  them  and  make  the  division. 

Tenotomy  of  the  sternomastoid  may  be  performed  subcutaneously  or 
by  open  incision.  The  operation  of  subcu- 
taneous tenotomy  is  one  of  great  deHcacy, 
and  not  entirely  free  from  risk,  three  fatal 
cases  having  been  mentioned  by  Mr.  Erich- 
sen.  Both  the  sternal  and  clavicular  origin 
may  require  division.  Anesthesia  is  neces- 
sary, and  the  dorsal  position  is  preferable, 
with  the  head  well  extended  and  rotated  to 
the  sound  side.  The  sternal  portion  is  best 
divided  about  half  an  inch  above  its  origin, 
from  within  outward.  Care  being  taken  to 
avoid  the  anterior  jugular  vein,  if  present,  a 
blunt-pointed  tenotome  should  be  intro- 
duced flatwise  in  front  of  the  upper  margin 
of  the  sternum  anterior  to  the  inner  edge  of 
the  muscle,  and  be  passed  outward  beneath 
the  deep  surface,  the  edge  turned  forward, 
and,  with  a  slight  sawing  motion,  the  tendon 
be  divided.  The  clavicular  portion  may  be 
divided  through  the  same  puncture,  but  is 
better  and  more  safely  accomplished  by  a 
second  puncture  between  the  two  portions, 
the  cautious  insertion  of  the  probe-pointed 
tenotome  behind  the  tendon,  and  its  division 
from  behind  forward.  After  the  division 
the  tenotome  must  be  withdrawn  flatwise, 
and  the  punctures  be  immediately  sealed. 
The  disadvantages  of  subcutaneous  teno- 
tomy are  the  difiiculty  of  dividing  the  deep 
bands  and  the  danger  of  wounding  im- 
portant vessels. 

Open  Incision:  In  aggravated  cases  the  deeper  cicatricial  bands  may 
be  preferably  divided  by  the  open  incision.  Under  full  aseptic  precau- 
tions, a  vertical  incision  along  thejnner  border  of  the  muscle,  or  preferably  an 


Fig.  189. — Popliteal  Space  (Deaver). 
Showing  relations  of  hamstring  tendons. 


ISS 


ORTHOPEDIC  SURGERY. 


incision  parallel  with  and  one  inch  above  the  clavicle,  should  be  made.  With 
forceps  and  the  handle  of  the  scalpel,  the  platysma,  the  muscle  sheath,  and 
cicatricial  bands  may  be  separated  and  divided  cautiously  upon  the  grooved 
director.  The  deeper  cicatricial  bands  should  be  firmly  secured  between  two 
strong  forceps  before  being  divided.  Great  care  must  be  exercised  to  avoid 
wounding  the  internal  jugular  vein,  by  relaxing  the  neck  and  not  opening  the 
deep  cervical  fascia. 

The  wound  should  be  sutured  with  catgut,  and  the  head  be  secured  in 


Fig.   igo. — Opex  Opeeatiox  for  Tenotomy  of  Biceps  Tendon. 


an  over-corrected  position,  by  plaster  or  silicate  of  soda  dressing,  or  other  me- 
chanical means,  for  from  ten  to  fourteen  days,  when  the  after-treatment  should 
be  begun. 

Division  of  the  Outer  Hamstring  Tendon  (Biceps). — The  contracted 
biceps  tendon  can  usually  be  located  beneath  the  skin.  It  is  best  divided 
by  an  incision  four  inches  in  length  carried  along  its  inner  margin.  The  in- 
cision may  be  made  in  such  a  manner  as  to  expose  both  the  inner  side  of  the 
biceps  tendon  and  the  outer  side  of  the  peroneal  nerve.     A  grooved  director 


TENOTOMY. 


189 


should  be  inserted  beneath  the  tendon  from  within  outward  so  as  to  avoid 
the  nerve.  If  there  is  any  doubt  about  the  position  of  the  peroneal  nerve  in 
the  incision,  it  is  best  to  expose  it,  if  possible,  so  that  it  will  not  be  divided. 
The  wound  should  be  closed  with  catgut  sutures  and  dressed  as  in  the  sub- 
cutaneous operation. 

Division  of  the  Tibialis  Posticus  Tendon. — The  subcutaneous  divi- 
sion of  this  tendon  requires  both  practical  knowledge  of  anatomy  and  pre- 
cision in  the  use  of  the  knife.      In  adults  the  tendon  is  so  prominent  that  at 


Fig.  191. — Open  Operation  for  Tenotomy  or  Tibialis  Posticus  Tendon. 


times  it  may  safely  be  divided  in  this  manner.  The  puncture  is  best  made 
about  two  centimeters  above  the  tip  of  the  internal  malleolus  in  a  line  drawn 
vertically  midway  between  the  posterior  border  of  the  malleolus  and  the  corre- 
sponding border  of  the  tendo  Achillis.  The  tendon  itself  must  always  be 
divided  by  means  of  a  blunt  tenotome  for  fear  of  wounding  the  posterior  tibial 
artery.  It  must  be  recollected  that  at  this  point  the  posterior  tibial  artery 
is  located  between  the  tendons  of  the  flexor  longus  digitorum  and  flexor  longus 
pollicis,  to  the  inner  side  of  the  former  being  the  tendon  of  the  tibialis  pos- 
ticus, and  to  the  outer  side  of  the  latter  the  posterior  tibial  vein  and  the  pos- 


190  ORTHOPEDIC  SURGERY. 

terior  tibial  nerve,  the  artery  being,  therefore,  the  middle  of  these  five  structures. 
The  internal  saphena  vein  and  nerve  are  superficial  and  anterior  to  the  punc- 
ture. The  blunt-pointed  tenotome  should  be  carried  perpendicularly  down- 
Vi^ard  to  the  depth  of  one  or  one-and-a-half  centimeters,  the  handle  made 
to  describe  the  arc  of  a  circle,  so  as  to  turn  the  cutting  surface  of  the 
blade  forward  and  against  the  tendon,  and  the  latter  be  divided  vertically 
inward.  Its  division  will  be  evidenced  by  a  slight  snap  and  a  slight  change 
in  the  position  of  the  foot.  The  danger  of  wounding  the  posterior  tibial 
artery  is  probably  exaggerated,  Adams  having  met  it  but  once  in  a  very  large 
experience,  and  Bonnet  having  wounded  it  more  than  once,  but  only  a  few 
times  and  without  subsequent  serious  injury.  In  Mr.  Adams's  case,  and  in 
a  similar  one  recorded  by  Mr.  Tamplin,  the  injury  resulted  in  a  false  aneur- 
ysm, but  both  patients  subsequently  recovered.  The  injury  to  this  vessel  is 
evidenced  by  a  florid  jet  of  blood  and  the  blanching  of  the  foot.  In  such  an 
event  a  firm  compress  should  be  accurately  applied  and  maintained  in  posi- 
tion by  a  roller  for  some  days.  This  may  be  sufficient,  as  in  a  case  recorded 
by  Agnew.  In  the  majority  of  cases  puncture  will  be  followed  by  aneurysm, 
which  will  require  ligation  of  both  ends  of  the  sac,  as  in  the  cases  recorded 
by  Tamplin,  Bradford  and  Lovett,  and  others. 

The  rule  laid  down  for  the  section  of  this  tendon  is  the  one  to  be  employed 
in  subcutaneous  division,  and  in  some  adult  cases  the  tendon  can  be  located 
with  great  ease  and  precision,  and  may  then  be  divided  by  simply  locating 
it  with  the  finger  and  cutting  forward  against  the  bone. 

On  account  of  the  difficulty  of  dividing  this  tendon  safely  it  is  better  to 
divide  it  by  the  open  method,  selecting  a  point  about  an  inch  above  the  usual 
locality  for  the  division  by  the  subcutaneous  method.  K  vertical  incision  is 
made  close  to  the  border  of  the  tibia,  beginning  at  a  point  one  inch  above  the 
tip  of  the  malleolus.  The  incision  is  carried  upward  an  inch  and  a  half,  the 
fascia  over  the  tendon  is  opened,  the  tendon  is  raised  upon  a  grooved 
director  or  dry  dissector,  and  divided.  The  wound  is  closed  by  one  or  two 
catgut  sutures. 

After-treatment  of  Tenotomy. — The  after-treatment  requires  as  much 
if  not  more  attention  to  detail  than  the  operation  itself,  and  on  this  depends 
much  of  the  success.  Indeed,  many  authorities  believe  treatment  to  have 
commenced  only  when  the  foot  has  been  straightened  by  forcible  means  and 
tenotomy. 

At  the  expiration  of  ten  days  the  foot  should  be  inspected,  and  if  in  good 


Fascia  of  leg 


Flexor  longus 
digitorum 


Internal 'malleo 


Deep  lamina  of  the  fascia 
of  the  leg 


Fig.  192. — Region  behind  the  Inner  Ankxe,  Natural  Size  (after  Von  Bardeleben  and  Haeckel). 
Showing  relations  of  posterior  tibial  tendon. 


TENOTOMY.  193 

condition  it  should  be  placed  in  a  well-constructed  mechanical  walking-shoe. 
At  least  once  a  day,  and  preferably  twice  a  day,  the  foot  and  leg  should  be 
rubbed  with  linimentum  saponis,  bathing  whisky,  or  extract  of  witch-hazel, 
and  manipulated,  particularly  over  the  muscles  and  tendons  which  were  for- 
merly contracted.  This  is  very  important  and  tends  to  free  and  strengthen 
the  tendons.  The  skin  over  bony  joints  subjected  to  pressure  should  be 
hardened  by  the  application  of  a  solution  of  alum  in  alcohol.  At  night  for 
some  months  the  foot  should  be  placed  in  a  retention  night-shoe,  by  which 
any  tendency  to  relapse  may  be  corrected. 

Electricity  should  not  be  omitted.  It  should  be  applied  to  the  whole 
part  to  improve  the  nutrition  of  the  skin  and  deeper  structures,  but  it  should 
be  more  particularly  applied  to  the  contracted  or  paralyzed  muscles. 

Tendon  Shortening. — Tendons  may  be  shortened  by  an  oblique  division 
and  an  overlapping  of  their  ends,  or  they  may  be  folded  upon  themselves,  or 
they  may  be  ruffled. 

In  shortening  a  tendon  by  the  first  method,  as  the  tendo  Achillis,  the  ten- 
don must  be  exposed  by  a  longitudinal  incision  and  lifted  on  a  grooved  director 
and  divided  in  the  direction  of  its  fibers  by  a  central  incision  which  is  cut  out 
at  each  end,  the  ends  being  secured  with  forceps.  The  cut  surfaces  are  then 
slid  past  each  other  and  the  deformed  part  is  placed  in  such  a  manner  that  the 
overlapping  may  be  accomplished.  Very  fine  sutures  are  inserted  to  hold  the 
cut  surfaces  in  position,  the  sheath  is  held  together  with  a  second  row  of  sutures, 
and  the  skin  is  held  together  with  a  third  row  of  sutures.  The  part  is  held 
in  the  corrected  position  until  a  plaster-of -Paris  cast  is  applied. 

Reeves  has  described  a  method  of  shortening  the  tendo  Achillis  which  is 
as  follows:  "An  incision  is  made  down  to  the  tendon,  the  sheath  is  opened, 
and  the  tendon  raised  by  a  blunt  hook  or  spatula,  and  folded  or  pinched  between 
the  fingers  until  the  size  of  the  piece  required  is  ascertained.  A  silver  suture 
is  then  passed  through  the  tendon  about  a  quarter  of  an  inch  above  and  below 
the  points  of  the  proposed  section,  to  prevent  a  slipping  away  of  the  tendon 
within  its  sheath.  The  segment  is  removed,  the  extremities  approximated, 
the  ends  of  the  wire  twisted  and  buried  in  the  tendon.  In  this  manner  one- 
half  to  two-thirds  of  an  inch  may  be  removed." 

Walsham  and  Willett  perform  an  operation  which  consists  in  dividing 
the  tendon  obliquely,  and  sliding  the  cut  ends  past  each  other  until  the  desired 
shortening  is  attained,  and  stitching  them  very  closely  together  with  chrom- 
icized  catgut  or  kangaroo  tendon,  including  the  skin  and  tendon.     Or  a  flap 

14 


194  ORTHOPEDIC  SURGERY. 

including  one-half  of  the  tendon  may  be  detached  and  stitched  to  another 
portion  of  the  tendon  which  has  been  freshened.  The  tendon  may  be  ruffled 
by  threading  a  needle  with  a  double  thread  and  passing  it  longitudinally 
through  the  tendon  several  times  and  drawing  on  the  thread  more  or  less 
tightly  before  it  is  tied. 

Transplantation  of  Tendons. — There  are  three  methods  of  transplant- 
ing tendons.  The  first  consists  in  dividing  the  tendon  of  a  sound  muscle  and 
inserting  it  into  a  slit  in  the  paralyzed  muscle ;  the  distal  extremity  of  the  divided 
tendon  is  again  attached  in  the  same  manner  in  an  upward  direction  into  a 
tendon  of  another  sound  muscle.  In  this  manner  the  tendon  of  the  extensor 
longus  pollicis  may  be  attached  to  the  tibialis  anticus  and  the  distal  extremity 
be  attached  to  the  extensor  communis  digitorum.  The  second  method  consists 
in  taking  a  slip  from  a  sound  tendon  and  inserting  it  into  a  slit  in  a  paralyzed 
tendon.  In  this  fashion  a  slip  from  the  extensor  longus  pollicis  may  be  attached 
into  the  tibialis  anticus.  The  third  method  consists  in  dividing  a  sound  tendon 
and  attaching  it  near  the  insertion  of  the  paralyzed  tendon.  The  distal  ex- 
tremity is  then  attached  to  another  sound  tendon.  For  example,  the  sound 
tendon  of  the  extensor  longus  pollicis  may  be  attached  to  the  periosteum  over 
the  scaphoid  bone,  the  distal  extremity  of  the  cut  tendon  then  being  attached 
to  the  extensor  longus  digitorum. 

The  greatest  care  must  be  observed  in  the  technic  of  this  operation  to  have 
it  thoroughly  aseptic.  Silk  boiled  in  a  i :  looo  sublimate  solution  is  considered 
■  by  many  to  be  the  best  material,  but  chromicized  catgut  may  be  used  in  some 
situations.  A  certain  amount  of  tension  on  the  muscles  is  necessary,  but  too 
much  tension  injures  the  muscles  and  too  little  tension  interferes  with  the  action 
of  the  tendon.  One  of  the  simplest  and  best  methods  of  transplanting  tendons 
is  to  carry  the  sound  tendon  into  a  slit  which  has  been  made  in  the  paralyzed 
tendon,  securing  it  in  place  with  interrupted  sutures.  Where  tendons  are 
carried  for  some  distance  for  purposes  of  transplantation,  tunnels  must  be 
made  for  them  with  a  blunt  instrument  beneath  the  subcutaneous  tissue.  Ten- 
dons may  be  transplanted  and  attached  at  a  new  point  in  the  periosteum,  the 
operation  consisting  in  suturing  the  tendon  to  the  periosteum  and  not  to  a  par- 
alyzed tendon.  The  advantage  claimed  for  this  operation  is  that  the  operator 
has  a  free  selection  of  the  point  of  insertion  for  the  transplanted  tendon.  Where 
the  tendon  is  too  short  to  reach  the  periosteal  insertion,  it  may  be  attached  by 
silk  strands,  which  afterward  become  inclosed  in  a  deposit  of  fibrous  tissue, 
layer  upon  layer,  an  intertwining  of  the  fibers,  so  that  it  becomes  after  a  time 
a  tendinous  band  in  the  center  of  which  is  the  silk  thread. 


TENOTOMY. 


195 


It  has  been  demonstrated  microscopically  that  the  regeneration  of  tendons 
after  transplantation  is  the  same  as  that  which  occurs  after  subcutaneous  tenot- 


FiG.  193. — Transplantation  of  Tendon  (Binnie). 

omy.  The  tendon-sheath  is  not  regenerated,  the  healed  tendon  is  grayish- 
white  in  color  from  the  cicatrices,  and  there  are  additional  tendinous  bands 
formed  from  irritation  and  extension  of  the  inflammation.     The  transplanted 


196  ORTHOPEDIC  SURGERY. 

tendon  heals  into  position  perfectly  without  much  reaction  in  the  transplanted 
tendon  itself. 

Aponeurotomy . — This  operation  consists  in  the  division  of  the  fascias 
when  they  are  contracted,  and  may  be  performed  by  the  subcutaneous  or  the 
pericutaneous  method.  The  latter  method  does  not  differ  greatly  from  the  divi- 
sion of  tendons  by  the  open  method,  the  fascia  being  raised  upon  a  grooved 
director  or  dry  dissector  and  freely  divided.  Aponeurotomy  is  employed  in 
the  division  of  the  palmar  fascia  for  contraction  of  the  hand,  the  division  of  the 
plantar  fascia  for  talipes  varus,  the  division  of  the  fascia  about  the  knee-joint 
in  contraction  of  the  knee,  or  in  the  division  of  the  fascia  lata  in  contraction 
of  the  hip  and  knee. 

Myotomy. — This  operation  consists  in  the  division  of  the  muscle  for 
extensive  contractions  and  is  indicated  where  division  of  the  tendons  is  not 
sufficient.  The  operation  is  usually  performed  by  the  open  method,  or  in 
some  situations,  as  about  the  hip-joint,  the  muscles  may  be  divided  subcutane- 
ously.  Extirpation  of  the  tensor  vaginae  femoris  for  internal  rotation  has 
been  successfully  performed  by  Gibney. 

The  transplantation  of  muscles  after  their  separation  from  their  origins 
or  insertions  may  be  considered  under  this  head.  The  transplantation  of  the 
pronator  radii  teres  from  the  inner  to  the  outer  condyle  has  been  introduced 
to  the  profession  by  Hoffa,  and  the  transplantation  of  the  sartorius  muscle 
into  the  biceps  femoris  has  been  advocated  by  Goldthw^aite. 

Neurotomy. — The  simple  division  of  a  nerve,  or  neurotomy,  is  not  em- 
ployed at  the  present  time  on  account  of  the  union  which  usually  occurs,  and 
which  defeats  the  purpose  of  the  operation. 

Neurectomy. — It  is  now  the  custom  to  remove  a  portion  of  the  nerve 
when  the  operation  is  performed  for  the  purpose  of  overcoming  spasm,  and 
this  form  of  operation  is  known  as  neurectomy.  Division  of  the  spinal  ac- 
cessory is  performed  for  intermittent  torticollis,  and  neurectomy  of  the  musculo- 
cutaneous has  been  proposed  for  erythromelalgia. 

Neurectomy  of  the  Spinal  Accessory. — The  nerve  may  be  conveniently 
exposed  by  an  incision  three  inches  in  length  along  the  posterior  border  of  the 
sternomastoid  muscle,  the  center  of  which  is  half  an  inch  above  the  center  of  the 
muscle,  or  on  a  level  with  the  upper  border  of  the  thyroid  cartilage.  After 
dividing  the  skin,  superlicial  and  deep  fascias,  the  head  may  be  flexed  and  the 
neck  relaxed  on  the  side  being  operated  upon,  the  muscle  may  be  separated 
with  a  grooved  director  and  the  finger,  and  turned  forward,  disclosing  the  nerve 


TENOTOMY.  197 

where  it  enters  the  muscle,  or  the  bottom  of  the  wound  may  be  irritated  with 
a  director,  the  contraction  of  the  muscle  serving  as  a  guide  to  the  location  of 
the  nerve. 

Neurorrhaphy,  or  Nerve  Suturing  (Neuroplasty;  Nerve  Anasto- 
mosis; Transplantation  of  Nerves). — In  cases  of  paralysis  produced  by 
the  loss  of  nerves  or  through  the  paralysis  of  the  nerves  operations  are  under- 
taken for  the  purpose  of  restoring  function.  Primary  suture  has  been  under- 
taken for  the  union  of  the  cut  ends  of  a  divided  nerve,  and  nerve-grafting 
operations  are  undertaken  in  order  to  restore  function  to  incised  or  paralyzed 
nerves. 

Nerve-grafting  may  be  accomplished  by  taking  a  slip  from  a  sound  nerve 
and  transplanting  it  into  a  paralyzed  nerve,  known  as  central  transplantation; 
or,  the  paralyzed  nerve  may  be  divided  and  the  distal  extremity  may  be  inserted 
into  a  slit  in  a  sound  nerve,  known  as  peripheral  transplantation  of  the  total 
central  type ;  or,  a  slip  of  a  paralyzed  nerve  may  be  taken  off  and  inserted  into 
a  slit  in  a  sound  nerve,  known  as  peripheral  transplantation  by  the  partial  cen- 
tral method. 

The  technic  of  this  operation  requires  the  same  aseptic  precautions  as 
for  the  open  method  of  tenotomy,  and  its  success  depends  upon  .the  use  of  small 
instruments,  eye  instruments  being  preferable,  and  as  little  manipulation  of 
the  nerves  as  possible.  The  divided  nerve  should  be  secured  in  the  slit  of  the 
sound  nerve  by  means  of  two  or  three  very  fine  chromicized  catgut  sutures 
attached  to  the  sheath,  and  the  transplanted  nerve  is  so  placed  that  the  central 
canal  is  in  contact  with  the  central  portion  of  the  sound  nerve  and  looking  in 
the  same  direction.  The  proximal  extremity  of  the  paralyzed  nerve  should 
be  inserted  into  a  neighboring  muscle  in  order  to  prevent  the  formation  of 
neuroma.  The  wound  should  be  closed  without  drainage  and  aseptic  dress- 
ing be  applied,  and  the  part  be  secured  for  from  four  to  six  weeks  in  a  plaster- 
of-Paris  dressing. 

In  acute  anterior  poliomyelitis  where  only  one  or  two  muscles  remain 
paralyzed  good  results  may  be  expected  from  the  anastomosis  of  the  nerve-supply 
of  the  paralyzed  muscles  with  a  motor  nerve  in  the  vicinity.  The  operation 
should  be  performed  preferably  at  about  six  months,  and  is  not  permissible 
within  three  or  four  months  after  the  acute  attack.  The  operation  is  most 
suited  to  those  cases  in  which  a  few  muscles  or  only  a  single  muscle  may  be 
paralyzed.  Operations  of  this  character  are  too  few  at  the  present  time  to 
give  any  definite  conclusions,  but  sufficient  success  has  been  met  to  encourage 


19S  ORTHOPEDIC  SURGERY. 

the  hope  that  satisfactory  results  will  be  attained  in  a  large  number  of  selected 
cases.  The  report  of  a  successful  operation  of  this  kind,  performed  by  the 
writer,  will  be  found  in  the  "Journal  of  the  American  Medical  Association," 
January  2 1 ,  1 905 .  In  this  instance  the  anterior  tibial  muscle  alone  was  paralyzed . 
An  incision  10  cm.  in  length  was  made,  including  the  skin  and  superficial  fascia 
over  the  head  of  the  tibia,  downward  in  the  bony  axis  of  the  leg.  The  division 
of  the  tibia  and  fascia  exposed  the  peroneal  nerve,  and  this  was  found  to  divide 
into  (i)  a  fasciculus  of  nerves  supplying  the  anterior  tibial  nerve,  (2)  the  an- 
terior tibial  nerve,  and  (3)  the  musculocutaneous  nerve.  The  branches  supply- 
ing the  anterior  tibial  muscle  were  divided  as  high  up  as  possible  and  inserted 
through  a  perforation  in  the  musculocutaneous  nerve,  when  they  were  secured 
on  the  outer  side  of  the  latter  with  fine  catgut  sutures.  Decided  improvement 
followed  the  operation,  and  the  control  of  the  muscle  subsequently  became 
almost  normal. 

A  later  operation,  not  yet  reported,  was  performed  for  paralysis  of  the 
peroneal  nerve,  the  external  popliteal  being  anastomosed  with  the  internal 
popliteal.  In  this  case  the  sensation  was  restored  within  twenty-four  hours 
and  some  improvement  in  the  motor  power  has  been  noted. 

An  operation  for  quadriceps  paralysis  has  been  proposed  by  Spitzy.  The 
long  branch  of  the  obturator  nerve  is  attached  to  the  cruralis.  Another 
form  of  nerve  transplantation  for  the  relief  of  paralysis  in  anterior  poliomy- 
elitis has  been  performed  by  Peckham.  In  this  the  healthy  nerve-fibers  were 
cut  and  united  with  the  degenerated  nerve-fibers.  This  was  followed  by  the 
rapid  restoration  of  partial  function. 

A  complete  bibliography  on  this  subject  will  be  found  in  the  "Zeitschrift 
f.  orth.  Chir.,"  Bd.  xiii,  Hft.  2. 


CHAPTER  VH. 
OSTEOTOMY. 

Osteotomy  for  the  relief  of  badly  united  fracture  has  been  performed  since 
the  time  of  Hippocrates.  '  Although  Rhea  Barton,  of  Philadelphia,  performed 
osteotomy  for  hip  ankylosis  as  early  as  1826,  and  Malgaigne  suggested  subcuta- 
neous osteotomy  in  1847,  it  was  not  until  1851  that  Meyer,  of  Wurzburg,  first 
performed  osteotomy  for  genu  valgum.  Operations  upon  other  articulations 
became  more  numerous,  and  were  performed  in  this  country  by  Pancoast, 
Sayre,  and  Brainard. 

The  operation  of  osteotomy  consists  in  a  subcutaneous  division  of  part 
of  a  bone  with  a  chisel  or  saw,  and  fracture  of  the  undivided  portion. 

The  osteotome,  or  bone-chisel,  is  a  ^bone-knife  and  should  be  employed 
as  such.  Different  widths  should  be  used,  the  temper  should  be  midway  be- 
tween the  temper  of  a  wood  and  cold  chisel,  the  point  should  gradually  taper 
so  as  to  avoid  a  shoulder,  and  the  side  should  be  marked  in  half  or  quarter 
inches  to  show  how  deeply  the  cutting-edge  has  penetrated.  The  instrument 
should  be  firmly  grasped  with  the  left  hand  with  the  thumb  against  the  head 
to  steady  it.  An  ordinary  carpenter's  mallet  answers  every  purpose  as  well 
as  the  more  expensive  instruments. 

Technic. — A  longitudinal  incision  is  made  in  the  skin  at  the  selected 
point,  the  osteotome  is  introduced  down  to  the  bone,  turned  at  right  angles 
to  the  shaft,  and  driven  into  and  nearly  through  the  bone,  by  a  few  blows  of 
the  mallet.  The  osteotome  is  partially  withdrawn,  its  direction  changed,  and 
another  section  made  until  the  interior  of  the  bone  is  divided.  The  instrument 
is  then  withdrawn,  and  the  bone  is  broken  by  manual  force;  a  catgut  suture 
is  inserted,  an  aseptic  dressing  is  applied,  and  the  part  is  fixed  in  an  over- 
corrected  or  corrected  position  as  desired.  Such  a  section  is  known  as  a  linear 
osteotomy. 

Several  modifications  of  linear  osteotomy  have  been  performed.  The 
combination  of  osteotomy  and  osteoclasis  has  been  recommended  by  Hopkins, 


200 


ORTHOPEDIC  SURGERY. 


an  interval  being  allowed  to  elapse  after  the  former  for  the  healing  of  the  wound, 
the  object  of  the  combination  being  the  greater  accuracy  of  the  fracture  over 
simple  osteoclasis.  There  is  no  advantage  in  submitting  a  patient  to  two  opera- 
tions when  one  will  suffice.  It  has  also  been  proposed  to  make  the  division 
in  the  bone  in  rachitic  deformities  with  a  Gigli  saw.  In  order  to  accomplish 
this,  more  exposure  of  the  parts  is  required  than  for  simple  linear  osteotomy, 
and  only  where  a  resection  of  a  cuneiform  piece  of  bone  is  necessary  is  this 
operation  justifiable. 

Another  form  of  osteotomy  which  is  of  value,  particularly  about  the  hip- 
joint,  is  performed  by  means  of  an  electric 
drill.  Parallel  holes  may  be  drUled  at  short 
intervals  in  the  direction  of  the  desired  sec- 
tion, after  which  the  bone  may  be  broken 


Fig.  194. — Macewen's  Osteotomes. 


Fig.  195. — Position'  of  H.\nd  in  Holding 
Osteotome. 


with  the  hand.  For  this  method  the  best  drill  is  the  electric  drill  of  Cryer, 
the  speed  and  direction  of  which  can  be  perfectly  controlled  by  the  surgeon. 

Vertical,  Longitudinal,  or  Oblique  Osteotomy.— A  valuable  im- 
provement of  linear  osteotomy  in  certain  localities  is  oblique,  vertical,  or  longi- 
tudinal section  of  the  bone.  This  requires  more  exposure  of  the  tissue,  in- 
volves more  danger  of  infection,  but  offers  the  advantage  of  lengthening 
the  bones  during  the  correction.  It  is  most  valuable  in  deformity  of  the  tibia 
and  for  ankylosis  of  the  hip-joint. 

Technic— An  incision  4  to  6  inches  long  is  made  at  the  selected  point, 
exposing  the   bone;    retractors  are  passed  about  the  entire  circumference  of 


Fig.  196. — Cryer's  Electric  Drill. 


OSTEOTOMY. 


203 


i 


k 


the  bone,  and  the  obHque  section  is  made  with  a  broad  osteotome.    The  divided 
bones  are  sHd  past  each  otlier,  and  secured  with  steel  nails,  silver 
wire,  or  simply  fixed  in  a  corrected  position  in  a  plaster-of-Paris 
cast.     The  length  of  the  bone  may  in  this  manner  sometimes  be 
increased  more  than  an  inch. 

Cuneiform  Osteotomy. — The  removal  of  a  wedge-shaped 
portion  of  bone  is  rarely  demanded  in  the  correction  of  rachitic 
deformities,  since  it  has  been  discovered  that  the  overriding  of  the 
fragments  can  be  prevented  by  tenotomy  of  the  contracted  tendons. 
In  severe  deformity,  and  occasionally  after  vicious  union  from  frac- 
ture, this  operation  is  desirable.  It  is  best  accomplished  by  first  per- 
forming a  linear  osteotomy  through  a  larger  incision,  and  then,  by 
protecting  the  soft  parts  with  retractors,  the  desired  section  may 


Handle  for  Cryer's 
Electric  Drill. 


Drills  tor  Cryer's  Electric  Drill. 
Fig.  197. 


be  separated;  or  the  end  of  one  fragment  may  be  pushed  out  of  the  wound 
and  the  section  be  removed. 


204 


ORTHOPEDIC  SURGERY. 


Chondrectomy  and  Chondrotomy. — In  deformities  due  to  the  unequal 
growth  of  the  bones  from  injur)'  or  disease  of  the  epiphysis  the  partial  or  com- 


OBLiQrE  Osteotomy 
OF  Tibia  (Joachims- 
thal). 


Same,  Lower  Frag- 
ment Slid  Down- 
ward (Joachimsthal). 


Fig.  198. 


ObLIQOT:   OSTEOTOilY  S.AUE        WITH       LOWER 

FOR  Hip-joiNT    (Joa-  Fragment     Pushed 

chimsthal).  Do'n'Xw.ARD        (Joa- 

chimsthal). 
Fig.  199. 


U^^ 


Oblique   Osteotomy  of  Shaft 
OF  Tibia  (Joachimsthal). 


S.AME,  Lateral  View. 
(Joachimsthal). 


Same,  Lower  Fr.^gmext  Ro- 
tated trpoN  t'pPER  (Joa- 
chimsthal). 


plete  resection  of  the  epiphysis  of  the  adjacent   bone  is  sometimes  followed 
bv  ?ood  results.      Thus  in  deformity  of  the  wrist  from  disease  of  the  lower 


OSTEOTOMY. 


205 


epiphysis  of  the  radius  the  removal  of  the  epiphysis  of  the  lower  end  of  the 
ulna  will  be  indicated  to  arrest  the  growth  and  correct  the  deformity. 

Arthrodesis. — The  production  of  an  artificial  ankylosis  by  the  removal 
of  a  part  or  all  of  the  cartilage  of  a  joint  has  been  performed  for  the  flail  joints 
due  to  paralysis.  The  operation  consists  in  opening  the  joint  by  a  suitable 
incision,  and  removing  with  a  knife  or  thin  chisel  a  thin  layer  of  cartilage  from 
opposed  surfaces  of  the  articulating  bones,  nailing  or  serving  the  parts  together, 


Fig.  20I. — Volkmann's  Double  CrREi. 


or  fixing  them  in  the  best  position  for  use  by  a  plaster  cast,  which  is  worn  until 
ankylosis  is  firm.  In  conjunction  with  tendoplasty  this  operation  furnished 
a  valuable  means  of  securing  a  useful  member.  Thus,  for  example,  in  talipes 
calcaneus  from  paralysis  of  the  anterior  group  of  muscles,  the  articulating  carti- 
laginous surfaces  of  the  mediotarsal  joint  should  be  removed.  The  Esmarch 
bandage  may  with  advantage  be  employed. 


Fig.  202. — Baeker-Willard  Irrigating  Curet. 

Erasions. — In  children  and  youths  the  removal  of  the  diseased  portion 
only,  or  erasion,  as  it  has  been  technically  named,  is  preferable  to  the  more 
formal  excisions  formerly  advocated.  These  offer  the  advantage  of  not  inter- 
fering with  the  growth,  and  admit  of  repeated  operations  in  case  of  failure 
to  arrest  the  disease  at  the  primary  operation.  The  extent  of  the  disease  should 
determine  the  selection  of  erasion  in  preference  to  excision,  and  the  .r-ray  will 


Fig.  203. — Allis's  Periosteotome. 

often  materially  assist  the  surgeon  in  arriving  at  a  proper  decision.  The  in- 
cision is  usually  made  over  the  seat  of  the  disease  or  through  sinuses  in  such  a 
manner  that  it  can  be  extended  in  the  lines  of  a  formal  excision  should  this 
become  necessary.  All  the  diseased  area  is  removed  with  thumb  gouge,  chisel, 
knife,  or  rongeur,  the  surrounding  parts  are  cureted,  cauterized  with  pure 
carbolic  acid,  neutralized  with  alcohol,   and  drained  with  tubes  and  packed 


206  ORTHOPEDIC  SURGERY. 

with  sterile  or  iodoform  gauze  and  allowed  to  heal  by  granulation,  the  part 
being  securely  held  by  a  plaster  cast. 

Articular  Resections. — In  adults  and  in  adolescents  where  the  disease 
is  extensive,  formal  articular  resections  are  to  be  recommended.  Resections 
are  also  performed  for  ankylosis,  and  under  these  conditions  attempts  are  some- 
times made  to  remove  angular  sections  of  the  articulating  surfaces  in  order  to 
correct  deformity,  and  Sayre  has  rounded  off  the  upper  end  of  the  femur  and 
deepened  a  cavity  in  the  lower  end  of  the  upper  fragment  so  as  to  establish 
an  artificial  joint.  If  the  fragments  can  be  kept  far  enough  apart,  this  might 
succeed ;  but  it  usually  fails,  as  in  the  case  reported  by  the  author.  A  modifica- 
tion of  this  is  seen  in  the  open  operation  for  congenital  dislocation  of  the  hip. 
The  new  cavity  may  be  made  without  difficulty  with  a  Doyen  borer.  In  re- 
section of  the  hip-joint  excellent  motion  is  not  unusual,  especially  if  the  acetab- 
ulum has  not  been  extensively  involved. 

Amputations. — In  orthopedic  practice  amputations  are  performed  for 
extensive  joint  disease,  for  malignant  disease,  and  for  incurable  deformities, 
such  as  in  club-foot  due  to  congenital  absence  of  parts. 

In  children  amputations  are  very  rarely  required,  but  in  adults  they  are 
often  necessary  early  in  the  disease.  The  indications  for  amputation  are  pro- 
longed suppuration,  extensive  disease  of  the  shaft,  and  albuminuria.  The 
special  indications  for  amputations  will  be  considered  in  the  appropriate 
chapters. 


PART  II. 

SPECIAL  ORTHOPEDIC  SURGERY. 


CHAPTER  I. 
POTT'S  DISEASE  OF  THE  SPINE. 

Pott's  disease  of  the  spine  is  a  progressive  tuberculous  lesion  of  the  verte- 
bral bodies  or  intervertebral  discs,  leading  to  their  partial  or  complete  destruc- 
tion, usually  terminating  in  ankylosis  with  the  characteristic  posterior  deformity. 

History. — It  is  so  called  from  the  accurate  description  of  the  disease  given 
by  Sir  Percival  Pott  in  1779.  He  described  it  as  a  "palsy  of  the  lower  limbs, 
which  is  frequently  found  to  accompany  a  curvature  of  the  spine,  and  is  sup- 
posed to  be  caused  by  it,"  and  ascribed  it  to  a  localization  of  unhealthy  ex- 
udates. Its  tuberculous  nature  was  first  pointed  out  by  Delpech,  Nelaton, 
and  the  earlier  French  investigators.  The  disease  was  recognized  by  the  an- 
cients, was  well  known  to  Hippocrates,  Galen,  and  the  earlier  writers  on 
medicine,  five  hundred  years  before  Christ,  and  had  also  been  previously 
described  by  Camper  and  Severin. 

Synonyms. — English,  Caries,  or  Osteitis  of  the  Spine;  Vertebral  Arthritis; 
Vertebral  Tuberculosis;  Angular  Curvature;  Posterior  Curvature.  Greek, 
Kyphosis.  French,  Mai  de  Pott;  Cyphose.  German,  Spitzbuckel;  Winkel- 
formige;  Kinkung  der  Wirbelsaule.  /to/m#,  Ciphosi;  Morbo  di  Pott.  Spanish, 
Mai  de  Pott.  Most  of  these  are  too  precise  pathologically  considered,  or  obvi- 
ously contradictory, — as  the  term  "angular  curvature,"  which  from  a  geometric 
point  of  view  would  correspond  to  a  round  triangle,  or  a  square  circle, — hence 
it  would  seem  best  to  retain  the  extensively  employed  "Pott's  disease,"  or,  if 
a  more  scientific  designation  is  required,  to  substitute  spondylitis  {^-(hSuhiq,  a 
vertebra)  as  being  the  least  open  to  objection. 

Frequency. — The  frequency  of  this  disease  in  surgical  practice  is  ex- 
hibited in  5680  orthopedic  cases,  of  which  1000  were  tuberculous,  treated  at 
the  Hospital  of  the  University  of  Pennsylvania  and  Polyclinic  Hospital,  of 
which  492  were  cases  of  this  affection.  These  were  taken  from  22,214  cases 
of  all  kinds,  of  which  Pott's  disease  represented  0.018  per  cent. 


208  ORTHOPEDIC  SURGERY. 

Relative  Frequency. — The  relative  frequency  as  regards  other  joints 
is  shown  in  the  following  from  my  own  statistics:  Pott's  disease,  416;  hip- 
joint  disease,  421;  knee-joint  disease,  103;  ankle-joint  disease,  33;  shoulder- 
joint  disease,  2;  elbow-joint  disease,  17;  wrist-joint  disease,  8. 

Beuthner  out  of  78,297  patients  found  280  cases  of  Pott's  disease,  or  0.36 
per  cent.;  Lorenz  out  of  32,424  patients  found  251,  or  0.75  per  cent.;  and  in 
1444  cases  of  deformity  treated  by  Hoffa,  142  were  cases  of  spondylitis,  or  9.83 
per  cent.,  and  these  were  taken  from  67,919  cases  of  all  kinds,  of  which  Pott's 
disease  formed  0.21  per  cent. 

Localization  of  the  Disease. — The  erect  position  of  the  human  body 
is  a  factor  in  the  production  of  this  deformity.  It  is  asserted  that  spinal  caries 
does  not  occur  in  quadrupeds.  Davy  suggests  that  caries  "is  possibly  one  of 
the  penalties  we  pay  for  walking  in  the  upright  position,"  while  Albrecht  assumes 
that  the  upright  position  is  the  chief  cause.  INIohr,  in  56  autopsies  of  osteitis 
of  the  spine,  found  the  affection  most  common  in  the  dorsal  region  {t,t,  in  56 
^cases),  next  in  the  lumbar  region  (27  times),  and  next  in  the  cervical  (12  times). 

In  100  consecutive  cases  taken  in  order  of  attendance  from  my  private 
case-books,  the  following  relative  frequency  was  observed:  14  cervical,  50 
dorsal,  and  36  lumbar. 

From  collected  statistics  it  would  appear  that  the  relative  frequency  with 
which  the  disease  attacks  different  portions  of  the  vertebral  column  is:  i, 
dorsal;  2,  lumbar;  and  3,  cervical.  In  286  of  my  own  cases  of  Pott's  disease 
there  was  the  following  involvement:  dorsal,  190;  lumbar,  80;  and  cervical, 
16.  Of  the  involvement  of  the  dorsal  region  the  relative  frequency  is  as  fol- 
lows: out  of  235  cases  of  dorsal  affection  there  were  44  upper,  66  middle, 
and  125  lower,  or  19  per  cent,  upper,  28  per  cent,  middle,  and  53  per  cent,  lower. 

In  regard  to  the  individual  vertebras  affected,  Billroth  and  Menzel  found 
the  order  of  frequency  as  follows:  First  and  second  cervical;  sixth,  fourth, 
and  eighth  dorsal;  fourth  and  fifth  lumbar;  tenth  and  ninth  dorsal;  and  the 
third  cervical. 

Etiology. 

Age. — Pott's  disease  occurs  at  all  periods  of  life;  it  is  seen  in  infancy, 
youth,  adult  life,  and  extreme  old  age;  Bryant  has  even  described  a  case 
occurring  in  the  fetus.  By  far  the  greater  number,  however,  occur  from  three 
to  fourteen  years.  Gibney  found  87  per  cent,  under  fourteen  years  of  age, 
7  per  cent,  between  twelve  and  fourteen  years  of  age,  and  4  per  cent,  over 
twenty-one  years  of  age. 


POTTS  DISEASE  OF  THE  SPINE.  209 

The  following  table  illustrates  well  the  relative  frequency  at  all  ages: 

Mohk:  Deachman:  Taylor:  Yodng: 

I'ERiOD.  j2  Cases.  i6i  Cases.  375  Cases.  429  Cases. 

One  to  five  years, 29  per  cent.  41  per  cent.  60.3  per  cent.  41.3  per  cent. 

Six  to  ten  years, 22       "  36       "  18  "  24  " 

Eleven  to  fifteen  years,  .  20       "  13.7    "  6.4       "  12.  i       " 

Sixteen  to  twenty  years,   16.7    "  S       "  6.8       " 

After  20  years, 11       "  4.3    "  15.8       " 

The  disease  may  be  limited  to  one  vertebra,  or  five  or  more  may  be  affected. 
Thus,  in  the  81  cases  collected  by  Bouvier,  in  31  cases,  one  or  two  vertebras 
were  affected;  in  26  cases,  three,  four,  or  five;  in  24  cases  more  than  five. 

Sex. — Age  is,  therefore,  a  predisposing  cause,  while  sex  appears  to  exercise 
but  little  or  no  influence.  Some  authors  agree  in  their  opinions  in  regard  to  the 
influence  of  sex  in  the  etiology  of  this  affection ;  those  who  believe  in  a  traumatic 
origin  consider  it  more  frequent  in  boys,  from  their  presumed  greater  liability 
to  injury.  Fisher  has  found  that  out  of  500  cases  treated  at  the  National  Ortho- 
pedic Hospital,  London,  261  were  males  and  239  females.  Mohr,  out  of  137 
cases,  found  69  males  and  68  females.  Gibney,  in  2466  cases,  found  1329 
males  and  11 26  females.  Taylor,  out  of  412  cases,  reported  234  males  and 
178  females.  Bradford  and  Lovett,  at  the  Children's  Hospital,  Boston,  had 
in  294  cases,  152  males  and  142  females.  From  the  combined  statistics  col- 
lected from  these  sources  there  were  3797  cases,  of  which  2045  were  males 
and  1752  were  females.  Allowing  in  this  estimate  for  the  preponderance  of 
females  over  males  in  the  population,  it  would  make  the  disease  appear  equally 
common  in  both  sexes,  and  correct  the  erroneous  impression  of  a  greater  preva- 
lence among  males. 

Heredity. — It  is  particularly  frequent  among  the  scrofulous,  or  those 
suffering  from  the  condition  known  as  strumous  diathesis — a  condition  which, 
irrespective  of  external  physical  appearance  or  hereditary  antecedent,  renders 
the  system  peculiarly  prone  to  chronic  catarrhs,  chronic  inflammations  of  the 
bones,  glands,  and  skin,  retrogressive  in  character,  occurring  without  adequate 
cause,  and  singularly  liable  to  tuberculous  infection;  those  in  whom  there  is, 
in  other  words,  a  constitutional  predisposition  to  caseation,  or  to  a  tuberculosis 
of  irritated  parts.  This  is  particularly  well  shown  in  the  association  of  Pott's 
disease  with  strumous  and  tuberculous  affections  in  other  parts  of  the  body, 
such  as  "white  swelling,"  caries  or  necrosis  of  bone,  phthisis,  etc.,  and  in  the 
antagonism,  pointed  out  by  Treves,  which  exists  between  such  strumous  dis- 
orders, by  which  two  such  affections  are  seldom  manifest  at  the  same  time. 

15 


210  ORTHOPEDIC  SURGERY. 

The  infection  of  the  lungs  from  the  vertebras  has  been  denied,  and  one  author- 
ity, Dr.  T.  T-  Mays,  has  never  seen  phthisis  associated  with  or  subsequent  to 
tuberculosis  of  the  upper  dorsal  or  cervical  vertebras.  I  have  seen  phthisis 
follow  dorsal  caries,  and  attribute  it  to  extension  through  the  bronchial  glands, 
and  I  have  also  seen  tuberculosis  of  the  suprarenal  glands  associated  with 
lower  dorsal  caries. 

The  tubercular  diathesis  and  tuberculosis  are,  then,  very  important  fac- 
tors in  the  etiolog}'  of  this  affection,  the  former  beiag  the  predisposition,  the 
latter  the  actual  infection.  In  this  connection  I  should  like  to  call  attention 
to  the  large  number  of  instances  in  which  the  tuberculous  diathesis  is  trans- 
mitted by  the  father,  and  is  exhibited  in  joint  tuberculosis  in  the  child  without 
the  mother  becoming  in  the  slightest  degree  infected. 

In  my  own  statistics  in  416  cases  of  Pott's  disease  a  hereditary  tuberculous 
taint  was  found  in  24  per  cent.,  and  in  185  cases  examined  by  Gibney  there  were 
76  per  cent,  with  a  hereditary  tuberculous  taint.  Lorenz  found  in  251  patients 
61  cases  of  heredity,  and  Vulpius  16  out  of  96  cases. 

Again,  while  the  diathetic  condition  is  important  as  a  predisposing  etio- 
logic  factor,  a  history  of  traumatism  is  usually  presented  as  a  direct  exciting 
cause;  mth  this  predisposition  to  chronic  inflammation  present  in  the  system, 
a  slight  injury,  or  an  undue  use  of,  or  pressure  upon,  certain  parts,  may  initiate 
the  disease.  The  various  exanthemata,  whooping-cough,  and  other  depressing 
diseases  of  childhood  are  often  directly  responsible  by  lowering  the  vitality 
and  permitting  the  progress  of  glandular  disease  and  the  dissemination  of  in- 
fectious elements. 

The  general  etiology  of  tuberculous  disease  of  the  bones  and  joints  has  been 
considered  in  Tuberculous  Joint  Disease,  in  Chapter  II,  Part  I. 

Pathology. 

The  pathologic  lesion  peculiar  to  Pott's  disease  is  a  destructive  osteitis 
terminating  in  interstitial  absorption  or  caries,  affecting  the  cancellous  structure, 
and  especially  the  anterior  portion  of  the  body;  it  may  involve  only  one  or 
several  vertebras.  As  a  tuberculous  lesion  it  does  not  differ  from  the  tuberculous 
osteitis  occurring  in  the  epiphyses  of  the  long  bones,  and  consists  essentially  of  a 
softening  or  medu'llization  of  the  bone  tissue,  the  various  steps  of  the  process 
(congestion,  formation  of  granulation  tissue,  and  degeneration  and  softening 
of  the  new  formations,  ^^^th  pus  formation,  caseation,  and  bone  absorption) 
following  each  other  in  slow  succession.     The  primary  lesion  is  usually  in  the 


POTT'S  DISEASE  OF  THE  SPINE. 


211 


body  of  the  vertebra,  but  it  may  begin  in  the  lamina  and  arches.  The  primary 
lesion  in  the  body  spreads  forward  to  the  prevertebral  ligament,  from  which 
it  extends  upward  and  downward.  The  tuberculous  process  spreads  by  con- 
tiguity, attacking  the  adjacent  vertebras  above  and  below.  In  this  manner 
several  bodies  of  the  vertebras  may  be  involved,  the  one  which  was  the  seat  of 
the  primary  focus  being  most  extensively  affected.  As  the  disease  progresses 
the  softening  and  absorption  of  the  anterior  portion  of  the  vertebra  render 

it  incapable  of  sustaining  the  superimposed 
weight,  and  it  is  crushed  and  absorbed,  in  this 
manner  producing  angular  deformity. 


Fig.  204. — Photograph  froxi  Specimen  of 
Dorsal  Pott's  Disease,  showing  Kypho- 
sis AND  Deformity  of  Thorax. 


Fig.  205. — Photograph  from  Specimen  of  Dorsolumbar  Pott's 
Disease,  with  Section  of  Vertebras  showing  Absorption  of 
Bodies. 


The  character  and  extent  of  the  kyphosis  or  deformity  will  depend  upon 
the  number  of  the  vertebras  destroyed.  If  only  one  or  two  bodies  are  destroyed, 
the  deformity  is  angular;  and  if  a  large  number  are  diseased,  the  deformity 
will  be  a  long  posterior  curve.  When  the  disease  is  rapid,  large  sequestra 
may  be  entirely  cut  off  by  areas  of  granulation  tissue,  producing  the  so-called 
"caries  necrotica."  The  necrotic  form  is  accompanied,  as  suggested  by  Konig, 
by  an  infected  tuberculous  embolus,  which  is  followed  by  an  infarction  process. 
The  French  have  described  the  same  process  as  tuberculous  infiltration.  The 
surrounding  structure  becomes  firmer  and  the  shape  of  the  vertebra  is  preserved. 


212 


ORTHOPEDIC  SURGERY 


The  adjacent  bone  is  affected  only  by  limiting  and  rarefying  osteitis,  and  a 
cavity  is  produced  which  is  not  filled  with  granulation  tissue,  but  which  con- 
tains a  piece  of  bone  unchanged  in  structure.  According  to  the  degree  of  crush- 
ing of  the  bodies  the  angle  formed  varies,  there  being  sometimes  an  obtuse 
angle,  a  right  angle,  or  an  acute  angle  formed. 


M 

^^1 

k. 

^^H 

m^  A 

^i^^^l 

^^^^^F~^ 

^-^9 

WL 

w^^^ 

^^1 

^BK^^f/^^^                                 «£R9p^| 

^^^1 

■[         .^t^    ^^jgjA 

■^^1 

n^.   ^K  Id^^H 

H 

[j^jl^l 

Fig.   2o6. — Specimen   of   Lumbar   Pott's   Disease 
(Philadelphia  College  of  Physicians). 


Fig.    207. — Specimen   of  Severe   Form  of  Dorsolumb.\e 
Pott's  Disease  (Philadelphia  College  of  Physicians). 


Occasionally  the  tuberculous  lesion  is  a  superficial  one  involving  a  large 
number  of  vertebras.  In  these  the  process  may  be  rapid,  pus  formation  usually 
occurs,  and  the  vertebras  remain  unaffected  by  the  disease  for  a  long  period. 
The  occurrence  of  primary  tuberculosis  in  the  arches  is  rare,  but  occasionally 
it  is  observed.     The  process  resembles  tuberculosis  of  the  ribs,  small  sequestra 


POTT'S  DISEASE  OF  THE  SPINE. 


213 


are  separated  and  the  arches  are  softened  and  friable.     The  destruction  of 
the  arches  permits  the  column  to  bend  laterally  and  scoliosis  results. 

The  deformity  may  even  be  absent  in  the  dorsal  region,  as  in  the  autopsy 
reported  by  Spiller,  in  which  a  tuberculous  mass  2|  inches  in  diameter  was  found 
on  the  outside  of  the  dura.  The  occurrence  of  deformity  of  the  chest  depends 
upon  the  location  of  the  disease  in  the  vertebras.  If  the  lateral  portions  are 
involved,  and  especially  the  attachment  of  the  ribs  to  the  vertebra,  deformity 
of  the  chest  will  result.  If  only  the  body 
of  the  vertebra  is  diseased,  deformity  of 
the  chest  may  be  entirely  absent. 


Fig.  208. — Caries  Neceotica,  showing  Crushing  of  An- 
terior Part  of  Body  (Specimen,  Philadelphia  College 
of  Physicians). 


Fig.  209. — Caries  Superficialis  and  Caries 
Necrotica  in  S.wie  Specimen,  showing 
Destruction  of  Body  (Philadelphia  College 
of  Physicians). 


Instead  of  being  limited  to  the  bodies  of  the  vertebras  the  intervertebral 
fibrocartilages  and  adjacent  soft  structures  may  be  involved,  or  in  exceptional 
cases  it  may  be  confined  to  the  intervertebral  substances.  The  destruction 
of  the  intervertebral  bodies  produces  a  peculiar  deformity  characterized  by 
extreme  bony  projections  which  replaces  the  angular  deformity  usually  present 
and  which  results  from  the  depression  of  the  vertebras. 

The  term  spondylolizenia  is  applied  to  the  deformity  produced  by  caries 


214 


ORTHOPEDIC  SURGERY. 


of  the  last  lumbar  vertebra  (spondylarthrocace)  and  the  top  of  the  sacrum. 
The  conditions  are  those  of  the  spondylolisthetic  pelvis  greatly  exaggerated. 
In  this  condition  the  angle  of  the  kyphosis  may  be  so  acute  as  to  cause  the  lower 
lumbar  vertebras  to  project  over  the  pelvic  brim  like  a  roof. 

In  that  class  of  cases  in  which  the  disease  terminates  in  interstitial  ab- 
sorption (caseation  without  suppuration),  designated  as  dry  caries,  or  caries 
sicca,  many  vertebras  are  generally  involved,  and  the  marked  angular  deformity 


1 

9 

r<i<ii^l 

HUh^iJ 

tH 

S>m 

^■^■|(^f^f|fl 

^J^|H 

^ 

Fig.  2IO. — Vertebral  Games,  showing  Com- 
plete Bony  Occlusion  oe  Canal. 


Fig.  211. — Dorsal  Caries,  showing  Acute 
Angle  from  Crushing  oe  Bodies  (Philadel- 
phia College  of  Physicians). 


is  replaced  by  posterior  curvature.  As  a  rule,  suppuration  is  entirely  absent 
in  these  cases,  but  where  they  assume  a  suppurative  phase,  especially  in  adults, 
the  course  is  usually  more  rapid. 

Abscess. — In  a  considerable  number  of  cases  suppuration  occurs,  and 
abscesses  form  and  find  their  e.xit  in  various  situations,  according  to  the  location 
of  the  affected  vertebras  and  the  resistance  of  the  fascias.  The  collections 
of  fluid  vary  in  character  and  size,  but  do  not  differ  from  tuberculous  abscesses 
elsewhere. 


POTT'S  DISEASE  OF  THE  SPINE. 


215 


In  order  to  re-establish  the  equilibrium  of  the  spinal  column  compensa- 
tory changes  occur  above  and  below  the  deformity.  When  it  is  in  the  cervical 
region,  marked  lordosis  of  the  dorsal  region  is  a  characteristic  sequence  and 
deformity  of  the  cranial  bones  may  occur.  When  the  dorsal  vertebras  are 
extensively  involved,  the  ribs  become  misshapen,  the  sternum  projects  forward, 
and  the  pelvis  becomes  flattened.  In  connection  with  the  formation  of  the 
kyphosis  certain  distortions  of  the  aorta  occur.  This  may  be  an  acute  V-shaped 
bend,  or  the  aorta  may  be  pushed  by  the  abscess  in  various  directions  in  a  C- 
or  S-shaped  form.  The  angle  may  be 
so  acute  as  to  constrict  or  diminish  the 
caliber  of  the  vessel. 


212. — -Specimen     of     Dorsolumbar 
(Wistar  Institute  of  Anatomy). 


-Lumbar    Caries  (Wistar   Institute 
of  Anatomy). 


The  pathologic  changes  in  the  membranes  and  cord  in  the  paraplegia 
which  accompanies  Pott's  disease  have  been  thoroughly  studied.  The  disease 
is  seldom  the  result  of  direct  pressure,  but  ordinarily  begins  as  a  pachymeningitis 
externus,  with  extension  by  contiguity  or  irritation.  The  result  of  this  is  a 
thickening  of  the  membrane,  compression  of  the  cord,  and  the  establishment 
of  a  compression  m3'elitis,  which  is  usually  the  cause  of  the  paraplegia.  Com- 
pression may  also  be  induced  by  the  direct  pressure  of  the  vertebras,  oblitera- 
tion of  the  canal,  caseous  depoits,  sequestra,  or  abscess  pressing  upon  the  an- 


216 


ORTHOPEDIC  SURGERY. 


terior  surface  of  the  cord.  The  paralysis  may  occur  before  the  deformity  from 
the  mechanical  pressure  of  an  abscess.  The  bony  canal  is  seldom  narrowed 
by  the  deformity,  and  some  specimens  with  extreme  deformity  are  free  from 
this  complication,  especially  where  abscesses  occur  and  discharge  upon  the 
surface  of  the  body.  Dislocation  of  the  odontoid  process  of  the  axis  may  occur. 
In  52  cases  of  autopsies  collected  from  literature  by  Schmaus  only  2  per  cent, 
of  the  cases  of  compression  were  due  to  direct  bony  pressure  from  the  deformity 
itself.  The  average  proportion  of  the  causes  of  the  paraplegia  was  78  per  cent, 
from  compression,  and  22  per  cent,  from  such  causes  as  meningomyelitis,  edema, 
hemorrhage,  sclerosis  or  diffuse  softening  of  the  cord 
itself.  The  compression  was  due  in  66  per  cent,  to 
caseous  tubercular  pachymeningitis,  produced  by  con- 
tiguity, and  in  10  per  cent,  to  dislocation  of  the  axis. 

When  the  violence  of  the  process  has  exhausted 
itself  the  process  of  repair  ensues,  the  vertebral  bodies 
and  arches  become  consolidated  and  protected  against 
sudden  dislocation  by  the  deposit  of  fibrous  tissue, 
caseous  masses  are  absorbed  or  encapsulated  or  cal- 
cified by  a  formative  or  osteoplastic  osteitis  which, 
beginning  early  by  the  development  of  osteophites 
from  and  in  front  of  the  bodies  of  the  vertebras,  has 
locked  together  and  fused  them  into  firm,  bony  an- 
kylosis. This  process  is  the  result  of  a  superficial 
spondylitis.  Beneath  the  anterior  ligament,  which 
acts  as  a  periosteum,  the  pus  spreads  over  many  ad- 
jacent bodies  of  the  vertebras,  producing  numerous 
foci  of  tuberculous  infection,  and  resulting  in  a 
roughening  and  grooving  of  the  surface.  The  intervertebral  bodies  are 
sometimes  softened  and  obscured. 


Fig.  214. — Angular  Bending 
OF  Aorta  from  Pott's  Dis- 
ease (Hoffa). 


Symptomatology. 

Taken  together,  the  symptoms  of  well-established  Pott's  disease  are  so 
characteristic  that  a  diagnosis  is  possible  almost  at  a  glance,  and  yet  few  dis- 
eases in  their  incipiency  present  such  variations  under  so  many  phases  as  does 
this  affection.  There  is  present  in  the  majority  of  cases  a  premonitory  stage, 
often  unobserved,  the  symptoms  of  which  are  included  in  the  comprehensive 
term  malaise — a  condition  between  vigorous  health  and  debilitating  sickness. 


Fig.  215. — Compression  Myelitis  from  Tuberculous  Mass  (Schulthess). 


^^i^ 


Fig.  2x6. — Microscopic  Section  of  Cord,  showing  Compression  Myelitis  from  Tuberculous  Mass 

(Spiller). 


POTT'S  DISEASE  OF  THE  SPINE. 


219 


a  want  of  energy,  an  irritability,  a  lowering 
calm  which  precedes  and  pre- 
monishes  the  coming  storm. 

Muscular  Spasm. — 
Among  the  first  and  most  im- 
portant symptoms  is  a  state  of 
spasm  or  muscular  rigidity  of 
the  spine.  This  is  an  early, 
always  present,  and  persistent 
sign,  due  either  to  reflex  mus- 
cular spasm  similar  to  that  con- 
stantly found  associated  with 
joint  disease  elsewhere,  or  an 
unconscious,  automatic  effort 
of  the  patient  to  avoid  motion 
or  prevent  and  diminish  jar  in 
the  affected  vertebras;  is  a  re-  j-j^  ,j, 
flex,  tetanoid  spasm,  accom- 
panied by  a  specific  atrophy, 
especially  of  the  erector  spins  group  of 


of  all  the  vital  functions,  an  inactive 


Fig.  2i8. — Cervical   Caries — First  and  Second  Cer- 
vical Vertebras.     Posterior  View. 


-Cervical   Caries — First  and  Second  Cer- 
vical Vertebras. 


muscles,  and  exhibits  itself  in  the 
peculiar  attitudes  assumed,  in 
the  diminished  normal  flexibility 
of  the  spine,  and  in  the  slight 
lateral  deviations  of  the  column 
sometimes  met  in  this  disease. 

Attitudes. — The  attitudes 
assumed  by  suft'erers  from  this 
aft'ection  are  characteristic  of  the 
different  parts  aft'ected.  In  the 
cervical  region  the  most  com- 
mon attitude  is  one  of  wry-neck. 
In  the  cervico-dorsal  region  the 
neck  is  pushed  forward  and  the 
chin  elevated,  the  shoulders  are 
drawn  up,  the  spine  below  the 
diseased  area  being  straight,  or 
in  a  condition  of  lordosis.     In 


220 


ORTHOPEDIC  SURGERY. 


the  dorsal  region  the  spine  is  curved  forward  above  and  below  the  seat  of  disease, 
the  shoulders  are  elevated,  the  body  is  shorter  than  normal,  and  the  rigid  spine 
gives  a  militar}'  attitude.     In  lumbar  caries  when  the  psoas  is  irritated,  or  a 

psoas  abscess  is  present,  the  patient  stands  upon 
one  leg,  the  thigh  of  which  is  flexed,  the  body  bent 
fora^ard  and  one  hand  resting  upon  the  knee. 
Children  with  cervical  caries,  when  fatigued,  grasp 
the  head  with  the  hands  about  the  sides  of  the 
face ;  in  dorsal  caries  they  rest  the  hands  upon  the 
hip,  or  in  sitting  on  a  chair,  upon  each  side,  or 
leaning  forward  rest  both  hands  upon  the  thighs. 
If  a  patient  suffering  from  this  affection  be  re- 
quested to  pick  up  an  object,  as  a  coin,  from  the 
floor,  instead  of  bending  the  spine  directly  forward. 
as  a  normal  individual  would  do,  he  holds  the  spine 
rigid  and  flexes  the  knees  and  lowers  the  whole 
body  in  a  squatting  manner. 

The  diminished  normal  flexibility  of  the 
spine  is  best  exhibited  when  an  attempt  is  made 
to  manipulate  the  aft'ected  part.  In  the  cervical 
region  if  the  head  is  carried  by  the  hand  of  the 
surgeon  toward  the  normal  position  the  whole 
body  will  be  carried  with  it.  When  dorsal  caries 
is  present,  the  child  should  be  placed  face  down 
across  the  knees  of  the  surgeon  seated,  with  the 
arms  and  legs  of  the  child  hanging  loosely  down, 
and  in  this  position  the  erector  spinae  muscles  wfll 
stand  out  prominently.  In  the  lumbar  region,  if 
the  child  is  placed  face  down  upon  a  couch  and  an 
attempt  be  made  to  lift  the  body  by  the  feet, 
instead  of  the  spine  arching  forward  it  wiU  be 
lifted  rigidly  en  bloc.  Slight  lateral  deviation  is 
present  in  certain  cases,  especially  the  dorsal  or 
dorsolumbar  regions,  dependent  upon  undue  muscular  contraction  or  unilateral 
destruction  of  the  vertebras. 

Pain. — Though  cases  are  recorded  where  pain  is  entirely  absent  tlorough- 
out  the  entire  course  of  the  disease,  it  is  usually  a  prominent,  distressing  symptom : 


Fig.  219. — Cervical  Caries 
SHOWING  Expression  of  Suf- 
fering. 


POTT'S  DISEASE  OF  THE  SPINE.  221 

the  fallacy  of  the  diagnostic  value  of  local  pain  is  now  fully  recognized.  When 
present,  it  is  usually  deep-seated,  dull,  subacute,  and  intermittent,  and,  as  a 
rule,  experienced  at  the  peripheral  distribution  of  the  irritated  nerves,  either 
at  or  below  the  affected  spot,  very  rarely  above  it,  except  in  some  cases  of  cervical 
caries.  It  may  be  subacute,  intense  and  lancinating,  accompanied  with  hyperes- 
thesia, or  may  only  amount  to  an  irritation.  Thus,  a  stiff  neck,  laryngeal  irrita- 
tion, gastralgia,  and  pulmonary,  intestinal,  gastric,  or  cystic  troubles,  are  fre- 
quently peripheral  symptoms  of  a  spinal  caries. 

Torticollis,  occipital  neuralgia,  bronchitis,  pneumonia,  cystitis,  and  gas- 
tralgia are  diseases  frequently  treated  for  this  affection,  and  in  one  remarkable 
case  lateral  lithotomy  was  performed  for  supposed  stone  in  the  bladder,  the 


Fig.  220. — Lumbosacral  Pott's  Dise.ase  with  Lupus  and  Tuberculous  Dactylitis. 

autopsy  of  which  exhibited  lumbar  caries.  The  writer  has  had  related  to  him 
a  case  of  caries  supposed  to  be  torticollis,  where  an  attempt  suddenly  to  correct 
the  deformity  resulted  in  sudden  death.  "Night  cries"  are  of  infrequent  oc- 
currence, but  a  peculiar  "grunting"  sound  is  frequently  emitted  by  sufferers 
from  cervico-dorsal  caries. 

Breath  Catch. — In  disease  of  the  dorsal  region  there  is  sometimes 
present  a  difficulty  in  the  respiration,  which  has  been  described  as  "breath 
catch."  It  is  produced  by  a  sudden  arrest  of  expiration  by  the  closure  of  the 
glottis,  the  sudden  release  producing  a  short,  mufHed,  cough-like  sound.  It 
is  probably  a  reflex  spasm  produced  by  the  pain  caused  by  the  compression 
of  the  diseased  vertebras,  or  the  costo-vertebral  articulation.     It  disappears 


222 


ORTHOPEDIC  SURGERY. 


upon  assuming  the  position  of  recumbency  and  is  most  marked  when  the  patient 
is  fatigued  from  over-exertion.  In  cervical  disease  this  is  sometimes  replaced 
by  a  grunting  sound. 

Deformity . — The  posterior  angular  curvature  is  the  most  conspicuous,  and 
often,  especially  in  hospital  practice,  the  first  symptom  which  directs  attention 
to  the  real  seat  of  the  disease;  it  results  from  the  breaking-down  of  the  vertebral 
bodies,  the  giving  way  of  the  anterior  support  of  the  column,  and  the  projection 
backward  of  the  spinous  processes.  As  pointed  out  in  speaking  of  the  pathology 
of  this  affection,  when  but  one  or  few  bodies  are  in- 
volved, it  is  sharp  and  angular;  when  many,  a  long 
and  gradual  antero-posterior  curve,  the  latter  cases 
being  usually  of  the  caries  sicca  variety;  when  angular 
and  median,  it  is  a  positive  sign  of  caries.  From  the 
anatomic  construction  of  the  vertebras  the  deformity 
will  reach  its  greatest  degree  of  development,  and  be 
most  conspicuous,  in  the  dorsal  region.     When  the  dis- 


FiG.  221. — Cervical  Caries,  showing  Attitude. 


Fig.  222. — Attitude  op  Rest 
IN  Dorsal  Caries  (Hoffa). 


ease  is  confined  to  a  single  vertebra,  it  alone  may  be  prominent  and  the  spinal 
column  may  preserve  its  normal  outline  above  and  below  the  prominence. 

Angular  curvature  may  be,  and  frequently  is,  absent  in  the  cervical  and 
lumbar  regions.  In  many  instances  there  is  added  to  the  lateral  deviation 
a  torsion  of  the  vertebra  in  an  opposite  direction  to  that  observed  in  scoliosis, 
thus,  in  Pott's  disease,  when  lateral  deviation  is  associated  with  convexity  to 
the  right,  the  rotation  of  the  spinous  processes  would  be  to  the  right.  More- 
over, this  deviation  is  a  distinct  leaning  or  acute  bending  of  the  body  toward 
one  side. 


Fig.    223. — Upper    Dorsal    Pott's 
Disease. 


224. — Mid-dorsal      Pott's 
Disease. 


Fig.  225. — Lumbar  Pott's  Disease. 


Fig.    226. — Dorsal    Caries    Recov- 
ered FKOII  PaR.APLEGIA  WITH  LoSS 

OF  Sens.ation. 


2  2  7- — Severe    Kyphosis 
IN  Dorsal  Caries. 


-Lumbar  Caries,  showing   Characteristic 
Dejormity.    Lateral  View. 


Fig.  229. — Lumbar  Caries,  showing   Characteristic 
Deformity. 
16 


Fig.  2JO. — Severe  Pott's  Disease, 
treated  Case. 


POTT'S  DISEASE  OF  THE  SPINE. 


227 


The  development  of  the  deformity  is  usually  gradual,  but  cases  of  rapid 
or  even  sudden  appearance  have  been  recorded,  and  indicate  an  active  and 
progressive  disease,  or  some  sudden  and  un- 
wonted action.  With  the  occurrence  of  the 
angular  projection  in  the  dorsal  region,  the 
configuration  of  the  anterior  portion  of  the 
chest  is  likewise  altered,  amounting  to  a  lateral 
flattening  and  "pigeon-breast." 

Abscess. — The  disease  may  run  its  en- 
tire course  without  suppuration,  but  in  the 
majority  of  cases  abscesses  form  a  constant 


Fig.  231. — LtTMBAR  Caries,  showing  Lateral  Deviation 
AND  ALSO  Position  of  Cicatrix. 


Fig.  232. — Pott's  Disease  with  Lat- 
eral Deviation,  prom  Caries  of 
THE  Vertebras. 


and  important  complication.  In  the  former,  caries  sicca  is  the  pathologic  lesion, 
and  a  "residual  abscess "  results,  as  pointed  out  by  Paget.  As  to  the  frequency  of 
abscess  formation,  statistics  vary.     Nebel,  in  54  patients  suffering  from  Pott's 


228 


ORTHOPEDIC  SURGERY. 


disease,  found  24  abscesses,  and,  according  to  Taylor,  abscesses  developed  in  14 
per  cent,  of  cases  of  kyphosis.  In  61  post-mortem  sections  upon  spondylitic 
patients,  Mohr  found  30  abscesses,  and  in  82  sections  Nebel  found  24  abscesses. 
Dollinger  in  700  cases  had  154  abscesses,  of  which  there  were  63  cervical  cases 
with  13  abscesses,  407  dorsal  cases  with  47  abscesses,  and  234  lumbar  cases 
with  94  abscesses.  The  relative  frequency  of  abscess  in  the  different  regions  is 
well  shown  in  the  183  cases  of  spondylitis  reported  by  Parker,  in  which 
about  8  per  cent,  of  the  cervical,  30  per  cent,  of  the  dorsolumbar,  and  70  per 
cent,  of  the  lumbosacral  cases  suppurated.  In  general  features  the  suppura- 
tions that  accompany  are  identical  with  the  cold  abscesses 
that  result  from  caries  elsewhere,  and  with  the  formation 
the  usual  apyretic  course  may  be  interrupted  by  an  eleva- 
tion of  temperature,  even  reaching  105°  F.,  as  recorded  by 
Schaffer.  As  a  rule,  however,  there  is  bu{  little  constitutional 
disturbance — a  slight  rise  of  evening  temperature,  slight  rigors, 
and  perspiration.  The  temperature  is  variable  and  somewhat 
characteristic,  even  where  an  abscess  cannot  be  discovered. 
There  is  usually  a  subnormal  temperature  in  the  morning  with 
a  slight  rise  in  the  evening  temperature.  It  seldom  goes  below 
981°  or  above  ioii°  F.  Any  decided  elevation  and  range 
of  temperature  would  indicate  the  presence  of  suppuration, 
which  is  well  shown  in  any  chart  from  a  case  of  spine 
disease  with  abscess.  Locally,  however,  abscesses  may  occa- 
sion much  disturbance  from  pressure  and  distention  of  sur- 
rounding parts,  or  may  assume  great  size  and  remain  stationary 
for  long  periods,  especially  in  children,  without  occasioning 
inconvenience;  these  collections  of  pus  follow  the  fascias  in 
the  direction  of  least  resistance,  and  usually  open  at  some 
distance  from  the  seat  of  origin ;  both  the  direction  and  termination  will  be  deter- 
mined by  the  region  of  the  spine  affected.  The  anatomic  importance  of  the  fascias 
in  protecting  important  parts  and  organs  is  evident.  Especial  attention  should 
be  directed  to  the  great  importance  of  the  cervical  fascia,  and  to  the  impor- 
tance of  the  fascias  generally  in  determining  the  direction  and  pointing  of 
abscesses  from  whatever  cause. 

Abscesses  in  the  cervical  region,  when  they  open  externally,  pass  between 
the  longus  colli  and  scaleni  muscles  to  appear  posterior  to  the  sternocleidomas- 
toid;  they  may,  however,  open  into  the  posterior  wall  of  the  pharynx  as  a 


Fig.  233. — Lumbar 
Abscess  (Hoffa). 


POTT'S  DISEASE  OF  THE  SPINE. 


229 


postpharyngeal  or  retropharyngeal  abscess,  or  may  burrow  beneath  the  deep  fascia 
into  the  thorax  and  form  a  mediastinal  abscess,  discharging  finally  into  the  trachea, 


Fig.  234. — Photograph  of  a  Cask  of  Bilateral  Fig.  235. — Same  Case  as  Foruee,  showing  Pos- 

LuMBAR  Abscess,  showing  Sinuses.  terior  Deformity  and  Lateral  Sinuses.]    j 


Fig.  236. — Lumbar  .and  Psoas  Abscess  (Hoffa). 


Fig.  237. — Psoas  Abscess  (Hoffa). 


esophagus,  or  through  an  intercostal  space.     In  rare  instances,  as  in  a  recent 
case  of  the  writer's,  the  pus  may  penetrate  the  pleura  and  form  an  empyema. 


230 


ORTHOPEDIC  SURGERY. 


In  the  dorsal  region  they  burrow  posteriorly  to  open  on  the  back  or  side 
a  short  distance  from  the  spine,  or  gravitate  beneath  the  ligamentum  arcuatum 
internum  within  the  sheath  of  the  psoas  magnus  muscle,  and  beneath  Poupart's 
ligament,  to  appear  externally  in  Scarpa's  triangle  as  a  psoas  abscess. 

The  external  opening  on  the  dorsal  aspect  may  communicate  directly 
with  the  lung,  as  was  illustrated  in  a  boy  under  my  care,  in  whom  iodoform 

emulsion  injected  into  the  sinus  was 
expectorated  with  violent  coughing. 
In  rare  instances  a  psoas  abscess  may 
find  its  exit  through  the  obturator 
foramen  and  discharge  through  the 
saphenous  opening. 

In  the  lumbar  region,  owing  to 
the  peculiar  anatomic  conditions,  pur- 
ulent collections  vary  much  in  their 
course  and  exit.  It  will  be  observed 
in  examining  a  sectional  diagram  of 
the  lumbar  region  that  the  sheath  of 
the  psoas  muscle  and  the  lumbar  fas- 
cia are  the  most  important  structures 
in  this  connection.  The  sheath  of  the 
psoas  is  a  thin,  fibrous  membrane  de- 
rived from  the  iliac  fascia,  attached 
above  to  the  ligamentum  arcuatum 
internum,  laterally  by  a  series  of 
arched  processes  to  the  interverte- 
bral substance  and  prominent  mar- 
gins of  the  bodies  of  the  vertebras, 
becoming  below  continuous  with  the 
Uiac  fascia.  The  lumbar  fascia 
divides  into  three  layers,  inclosing  the  quadratus  lumborum,  multifidus 
spinje,  and  erector  spinae  muscles,  and  giving  attachment  to  the  internal 
oblique.  Its  anterior  and  middle  layers  are  attached  to  the  transverse 
processes,  and  its  posterior  layer  to  the  spinous  processes.  Above,  its  anterior 
layer  is  attached  to  the  lower  border  of  the  last  rib,  forming  the  ligamentum 
externum.  The  posterior  surface  of  the  psoas  muscle  is  separated  from  the 
quadratus  lumborum  by  the  anterior  layer  of  the  lumbar  fascia — a  very  thin 


Fig.  238. — LuTVTBAR  Caeies  warn  Psoas  Abscess. 


POTT'S  DISEASE  OF  THE  SPINE. 


231 


fascia — but  the  greater  part  of  the  muscle  is  firmly  supported  behind  by  the 
erector  spinas  muscle.     In  front,  the  quadratus  lumborum  is  very  thin  and 


Fig.  239. — Double  Psoas  Abscess. 


Fig.  240. — Lower  Dorsal  Caries  with 
LuMBo-PsoAS  Abscess,  showi.n'g  Cica- 
trix FROM  Incision. 


offers  but  little  resistance  to  the  exit  of  the  pus.  The  sheath  of  the  psoas  and 
the  lumbar  fascias,  thin  as  they  are,  nevertheless  are  essential  factors  in  deter- 
mining the  direction,  and  w^ith  the  direction  the  prognosis,  of  lumbar  abscesses. 


232 


ORTHOPEDIC  SURGERY. 


So  important  do  these  fascias  appear  to  the  writer  that  he  has  suggested 
a  division  of  lumbar  abscesses  into  external  abscess  and  internal  abscess,  their 
relation  to  the  sheath  of  the  psoas  fascia  and  the  anterior  layer  of  the  lumbar 
fascia  determining  their  position.  They  may  pursue  a  course  like  that  of  the 
psoas  abscess  and  terminate  similarly;  may  burrow  backward  and  laterally  along 
the  middle  layer  of  the  lumbar  fascia,  separating  the  quadratus  lumborum  from 
the  internal  oblique,  through  the  internal  oblique  and  between  the  external 
oblique  and  latissimus  dorsi,  to  appear  at  the  outer  border  of  the  erector  spinae 
muscles,  in  the  triangle  of  Petit,  constituting  lumbar  abscess;  may  gravi- 
tate beneath  the  internal  iliac  muscles  over  the  posterior  brim  of  the  pelvis, 
perforating  the  great  sacrosciatic  foramen  as  a  gluteal  abscess ;  or,  if  the  abscess 
find  exit  upon  the  surface  of  the  vertebras  anterior  to  the  attachment  of  the 
psoas  fascia,  it  will  terminate  by  burrowing  along  the  great  vessels,  or  become 
an  iliac  abscess,  to  again  terminate  as  a  gluteal  abscess.  After  becoming  an 
iliac  abscess,  the  pus  may  rupture  into  the  intestines,  bladder,  vagina,  or  rectum, 
and  I  have  seen  a  case  of  fistula  in  ano  which  had  resulted  from  a  spinal  abscess. 
These  represent  the  usual  classic  courses,  but  cases  are  reported  in  which 
the  pus  has  traveled  great  distances  and  discharged  into  the  viscera  or  external 
parts  remote  from  the  seat  of  origin. 


ORIGINAL   TABLE   OF   SPINAL   ABSCESSES. 


Variety. 

CorRSE. 

Exit. 

a. 

Anterior. 

Into  posterior  wall  of  pharynx. 

b. 

Burrow  beneath  deep  fascia  into 

Into  trachea,  esophagus,  or  through 

Cervical • 

thorax  as  mediastinal  abscess. 

an  intercostal  space. 

c. 

Laterally  between  the  longus  colU 
and  scaleni  muscles. 

Posterior  to  the  sternocleidomastoid. 

r 

a 

Burrow  posteriorly. 

On  the  back  or  side  a  short  distance 

Dorsal -| 

1 

from  the  spine. 

b 

Within  psoas  sheath. 

Beneath     Poupart's      Ugament'     in 

I 

Scarpa's  triangle. 

• 

a 

Enter  psoas  sheath. 

As  psoas  abscess. 

b 

Burrow  between  the  fascias  of  the 

Posteriorly  beneath  the  external  ob- 

quadratus    lumborum    and   ab- 

hque  and   latissimus  dorsi    at  the 

dominal    muscles,    through   the 

outer  border  of  the  erector  spinae 

internal  oblique. 

muscle. 

Lumbar ■ 

c. 

Gravitate  beneath  the  internal  iliac 
muscles  over  the  posterior  brim 
of  the  pelvis,  perforating  the  great 
sacro-sciatic  foramen. 

-As  gluteal  abscess. 

I 

d 

May  be  directed  to  the  iliac  region 
along   the   aorta    and    external 
ihac  arteries. 

.-Xs  gluteal  abscess. 

Paraplegia. — The  paraplegia  of  the  lower  extremities  which  so  frequently 
accompanies  and  complicates  the  disease,  especially  in  the  cervico-dorsal  region, 


Fig.  241. — Diagram  of  Lumbar  Fascia  (Deaver). 


POTT'S  DISEASE  OF  THE  SPINE. 


235 


must  be  distinguished  from  that  which  results  from  compression  of  the  spinal 
cord  in  cases  of  extreme  distortion;  it  involves  generally  only  the  motor  area 


Fig.  242. — Spastic  Paraplegia  in  Pott's  Disease. 


Fig.    243. — Pott's    Disease   with   Sp.asmodic 
Paraplegia. 


of  the  cord,  and  occurs  in  the  acute  stage  of  caries  from  reflex  paralysis  due  to 
some  obstruction  to  the  blood-supply,  or  to  communication  of  the  inflammatory 


236  ORTHOPEDIC  SURGERY. 

action  by  contiguity  from  the  seat  of  the  disease  to  the  peri-meningeal  areolar 
tissue  and  membranes  of  the  spinal  cord — a  pachymeningitis,  or  meningo- 
myelitis.  The  symptoms  are  those  of  a  compression  myelitis — gradual  loss 
of  power,  with  increased  reflexes,  exaggerated  patellar  reflex  and  increased 
ankle  clonus  in  the  early  stage,  followed  by  complete  loss  of  power,  contracture 
of  muscles,  atrophy  of  paraplegic  parts,  and  loss  of  sensation  in  the  later  stages. 
In  some  instances  after  the  loss  of  sensation  there  occurs  a  stage  of  spasmodic 
contractions  of  the  entire  lower  extremities,  the  limbs  being  in  a  condition  of 
spastic  rigidity.  Should  the  power  return  while  this  condition  remains,  the 
scissor-leg  deformity  present  interferes  greatly  with  the  progression.  The 
general  health  is  but  little  affected,  and  the  bladder  and  rectum  are  not  disturbed, 
except  when  the  lumbar  portion  of  the  cord  is  involved,  or  toward  the  end  in 
very  severe  cases.  In  severe  types  where  incontinency  is  marked,  priapism 
and  cystitis,  with  pressure  bedsores  and  septicemia,  add  to  the  distress  of  the 
sufferer.  The  average  duration  before  the  appearance  of  paralysis  is  about 
three  years,  although  it  has  appeared  as  early  as  four  and  a  half  months,  and 
as  late  as  eleven  years.  The  paralysis  may  remain  stationary  for  a  long  period, 
and  regression  finally  occur  and  progress  to  a  complete  recovery.  In  the 
59  cases  reported  by  Taylor  and  Lovett,  the  duration  was  never  over  three 
years,  except  in  one  case,  where-  it  lasted  for  six  years.  Recurrence  was 
observed  in  6  cases,  4  cases  having  two  attacks,  and  2  having  three  attacks. 
It  occurs  in  any  number  of  consecutive  cases  in  about  the  same  proportion 
(being  somewhat  modified  by  early  treatment),  but  much  more  frequently 
complicates  the  disease  in  the  upper  than  in  the  lower  part  of  the  canal,  for 
obvious  anatomic  reasons.  Thus,  in  the  analysis  of  295  patients  suffering 
from  Pott's  disease,  Gibney  found  that  paralysis  occurred  in  62  in  the  course 
of  the  affection,  59  of  these  complicating  189  cases  of  disease  in  the  upper  dorsal 
and  cervical  regions,  and  only  3  complicating  106  cases  of  the  affection  in  the 
lower  portion  of  the  canal.  Recovery  follows  under  efficient  treatment  in 
many,  even  when  sensation  has  been  lost,  and  when  it  occurs  is  generally  complete. 
Relapses  may  occur  two  or  three  times.  The  extreme  distortion  of  the  thorax 
may  produce  pressure  neuritis  of  a  severe  type.  In  one  patient  the  pain  was 
so  acute  that  I  had  to  resect  a  portion  of  a  rib  for  its  relief.  The  same  patient 
had  in  his  youth  a  paralysis  of  one  leg  from  lateral  pressure. 

Diagnosis. 

The  importance  of  an  early  diagnosis  cannot  be  overestimated;    to  this 


Fig.  244. — Cervical  Caries — First  and  Second  Cervical  Vertebras.     Skiagraph. 


Fig.  245. — Cervical  Caries — Second  Cervical  Vertebras  (Skiagraph).    Lateral  View 


Fig.  246, — Skiagraph  of  Lower  Dorsal  Caries. 


17 


POTT'S  DISEASE  OF  THE  SPINE.  243 

end  the  examination,  both  oral  and  physical,  should  be  most  thorough  and 
painstaking.  The  entire  back  should  be  exposed  in  good  light,  and  the  flexi- 
bility of  the  spinal  column  tested,  either  standing,  by  the  method  of  Adams 
(by  placing  the  heels  together,  the  lower  extremities  extended,  and  the  body 
flexed  as  far  forward  as  possible),  or  prone  upon  a  hard  couch.  In  children 
the  latter  position  is  the  better.  The  surgeon  places  his  left  palm  upon  and 
fixes  the  pelvis,  and  gi-asping  the  feet  with  the  right  hand,  flexes  the  knees, 
and  ascertains  the  amount  and  range  of  flexibility.  In  small  children  a  high 
degree  of  flexibility  should  be  present.  In  obscure  cases  this  examination 
should  include  the  inspection  of  the  pharynx,  accurate  measurements,  and 
electric  and  other  reactions  of  the  extremities,  examination  of  the  major  articu- 
lations and  the  temperature. 

X-Ray  Photography. — The  examination  of  the  spine  by  means  of  the 
x-ray  is  of  great  value.  Not  only  can  the  amount  of  disease  and  the  character 
of  the  lateral  deviation  be  determined,  but  in  some  instances  the  abscess  may 
be  distinctly  outlined,  if  present,  as  in  the  a;-ray  of  the  cervical  region  on  page 
237.  The  extent  of  the  disease  in  the  vertebras  may  often  be  very  clearly  demon- 
strated by  this  means,  and  the  spreading  of  the  disease  to  adjacent  vertebras 
may  sometimes  be  discovered. 

The  size  and  course  of  large  abscesses  may  be  outlined  by  the  use  of 
substances  thrown  into  their  cavities,  but  these  methods  are  not  of  much  practical 
value. 

Differential  Diagnosis. 

There  are  so  many  diseases  which  have  been  mistaken  for  this  affection 
that  the  examination  should  consist  essentially  of  a  differential  study  (i)  of 
the  spinal  deformity,  (2)  of  the  cord  and  nervous  symptoms,  and  (3)  of  the  abscess, 
or  of  all  three  conditions  if  present. 

The  Differential  Diagnosis  of  the  Deformity. — The  kyphosis  is 
characterized  by  its  angularity,  median  position,  and  rigidity;  so  marked  are 
these  peculiarities  that  confusion  with  lateral  curvature  is  not  likely  to  ensue, 
except  in  those  cases  of  Pott's  disease  where  there  is  marked  lateral  deviation. 
These,  as  pointed  out  before,  are  chiefly  muscular,  and  are  accompanied  by 
an  exacerbation  of  all  symptoms,  which  with  the  rigidity  of  the  spine  would 
serve  to  distinguish  them.  Aneurysms  of  the  thoracic  and  abdominal  aorta 
eroding  into  the  vertebral  bodies  give  rise  to  symptoms  characteristic  of  caries, 
as  in  cases  recorded  by  Quincke  and  Roberts;   but,  in  addition,  the  symptoms 


244  ORTHOPEDIC  SURGERY. 

of  aneurysm  would  be  associated,  and  the  extensive  curve,  localized  pain,  and 
late  period  of  life  at  which  they  occur,  would  render  the  diagnosis  patent.  The 
same  considerations  would  eliminate  carcinoma,  sarcoma,  and  other  malignant 
growths.  For  the  differential  diagnosis  of  scoliosis,  sarcoma  of  the  spine, 
syphilis,  typhoid  spine,  and  phosphorus  necrosis,  the  reader  is  referred  to 
the  chapter  in  which  they  are  considered.  Rheumatoid  arthritis  of  the 
spine,  or  spondylitis  deformans,  is  characterized  by  its  occurrence  late 
in  life,  stiffness  and  arching  of  the  spine,  and  the  absence  of  kyphosis, 
abscess  and  muscular  spasm.  Vertebral  osteomyelitis  is  characterized  by 
acute  onset,  rapid  suppuration,  rigors,  remarkable  febrile  alterations,  rapid 
pulse  and  respiration,  diarrhea,  etc.,  and  extensive  denudation  and  de- 
struction of  the  vertebra.  A  differential  diagnosis  from  functional  spinal 
debility,  rachitic  curve,  etc.,  is  easily  made  and  need  not  be  dwelt  upon  here. 
In  young  children  muscular  rigidity  and  local  pains  over  the  vertebral  articu- 
lations may  be  present  in  rachitic  curves  to  a  marked  degree,  but  the  curves 
are  longer,  less  angular,  more  flexible,  and  always  associated  with  other  evidences 
of  rickets.  The  presence  of  pseudo-palsy  from  periosteal  tenderness  may 
render  the  diagnosis  more  difficult. 

The  Differential  Diagnosis  of  the  Paraplegia. — The  cord  and  nerve 
symptoms  will,  in  the  majority  of  instances,  be  found  associated  with  marked 
kyphosis,  or  at  least  rigidity  of  the  spine.  In  those  rare  cases  in  which  paraplegia 
occurs  without  angular  deformity,  the  latter  symptom,  and  possibly  a  purulent 
collection,  will  assist  the  diagnosis.  It  is,  however,  in  those  neuromimeses, 
or  so-called  "hysteria  of  the  spine,"  that  the  greatest  difficulty  is  encountered, 
and  especially  when  associated  with  "hysteric  paraplegia";  here  the  hysteric 
simulation  closely  resembles  the  genuine  disease,  but  the  pain  is  localized 
posteriorly  and  apparently  acute ;  there  is  no  reflex  spasm ;  the  muscular  rigidity 
yields  under  gentle,  firm  pressure;  and  the  paraplegia  is  usually  sudden.  It 
occurs  usually  in  young  neurotic  women  of  pronounced  brunet  type,  and  there 
is  usually  associated  ovarian  tenderness,  the  globus  hystericus,  and  other  evidences 
of  this  condition.  From  hysteric,  hyperesthetic,  or  neuromimetic  spine  the 
same  conditions  would  aid  in  differentiation ;  but  the  absence  of  bony  deformity, 
the  exaggerated  localized  tenderness  and  pain,  and,  as  a  rule,  the  absence  of 
real  muscular  spasm  will  render  the  nature  of  the  affection  patent.  In  the 
neurasthenic  spine  sometimes  observed  in  youth,  the  muscular  spasm,  paraplegia, 
and  occasionally  kyphosis,  are  confusing,  but  the  existence  of  spasms,  contrac- 
tions, and  hyperesthesia  in  other  portions  of  the  body,  and  the  general  hysteria 


POTT'S  DISEASE  OF  THE  SPINE. 


245 


will  solve  the  problem.  In  severer  cases,  and  after  railw^ay  injury,  or  ligamentous 
traumatism  from  any  cause,  excessive  muscular  spasm  is  induced  by  flexion. 
In  a  recent  case  of  this  character  without  medicolegal  interest,  in  an  eleven- 
year-old  girl,  the  history  of  injury  and  subsequent  suffering,  the  absence  of 
deformity,  the  excessive  spasm  and  atrophy  of  the  erector  spinse  group  of  muscles, 
rendered  the  diagnosis  clear.  From  muscular 
rheumatism,  lumbago,  etc.,  it  is  distinguished 
by  a  history  of  associated  rheumatic  affections, 
the  diftuseness  and  extent  of  the  pain,  and  the 
later  period  of  life  at  which  the  rheumatic 
affections  occur. 

There  are,  moreover,  several  affections 
commonly  mistaken  for  Pott's  disease  which 
deserve  more  thorough  consideration.  They 
are  hip  disease,  sacro-iliac  disease,  and  in- 
fantile paralysis. 

Differential  Diagnosis  of  the  Ab- 
scess.— The  abscess  accompanying  Pott's 
disease  may  be  diagnosticated  from  purulent 
collections  from  other  causes  and  neoplasms 
in  general.  In  the  cervical  region  it  is  liable 
to  be  mistaken  for  simple  abscess  and  adenitis. 
The  former  are  usually  acute,  attended  with 
fever,  and  superficial  in  character.  In  the 
latter  the  inflammation  is  circumscribed, 
deep-seated,  and  unattended  with  the  char- 
acteristic spastic  sensation. 

In  the  dorsal  region  chronic  pleurisy  with 
effusion  or  empyema,  other  inflammatory  pul- 
monary affections,  and  malignant  growths  are 

to  be  distinguished  by  the  physical  signs.  In  the  lumbar  region  abscess  must  be 
distinguished  from  simple  chronic  abscess,  abscess  of  lum.bar  glands,  abscess 
from  caries  of  the  ilium,  perinephritic  and  pericecal  abscesses.  The  condition 
of  the  psoas  muscles  will  best  indicate  the  presence  or  absence  of  pus  within 
its  sheath.  In  simple  chronic  abscess  the  symptoms  of  systemic  disturbance 
are  marked  rigor,  hectic  fever,  night-sweating,  while  those  of  vertebral  caries 
are  negative.     Perinephritic  and  pericecal  abscesses  are  distinguished  by  the 


Fig.  247. — Pott's  Disease  with  Hip- 
joint  Disease  Resembling  Sarcoma 
OF  Spine. 


246 


ORTHOPEDIC  SURGERY. 


marked  local  symptoms,  some  disturbance  of  the  organ  about  which  the  pus 
has  collected,  the  condition  of  the  psoas  muscles,  and  the  absence  of  all  the 
characteristic  manifestations  of  Pott's  disease.  When  the  abscess  opens  into 
and  is  discharged  from  the  vagina,  an  attempt  may  be  made  to  distinguish 
it  from  the  blennorrhoea  infantilis  by  the  examination  of  the  pus  for  bacilli 
of  tuberculosis  and  for  gonococci. 

The  psoas  abscess  pointing  below  Poupart's  ligament  to  the  outer  side  of 
the  femoral  vessels  may  be  mistaken  for  the  abscess  of  hip  disease,  femoral 
hernia,  cancerous  tumor,  bubo,  fatty,  cystic,  and  other  fluctuating  tumors; 
varicose  saphenous  vein,  aneurysm,  hydrocele  of  the  inguinal  canal,  undescended 
testicle,  etc.;  the  differential  diagnosis  of  which  may  be  rendered  clear  by  the 
characteristic  signs  of  each  of  these  affections,  and  the  absence  of  the  positive 


Fig.  248. — Testing  for  Psoas  and  Lumbar  Abscess  in  Pott's  Disease. 


signs  of  spinal  caries.     The  difference  between  the  abscesses  of  hip  disease 
and  those  of  spondylitis  is  well  shown  by  the  tables  on  pages  232  and  319. 

Caries  of  the  last  lumbar  vertebra  is  often  mistaken  for  osteitis  of  the  hip, 
and  vice  versa.  The  differential  diagnosis  is  at  times  exceedingly  difficult 
to  make,  and  for  details  the  reader  is  referred  to  the  chapter  upon  Hip-joint 
Disease.  Sacro-iliac  disease  may  be  distinguished,  if  occurring  in  young 
adults,  by  the  position  of  the  swelling  over  the  sacro-iliac  joint,  pain  caused 
by  pressure  of  the  sides  of  the  pelvis  together,  and  the  absence  of  lumbar  spinal 
deformity.  The  dift'erential  diagnosis  of  lumbar  Pott's  disease  from  hip  disease 
and  sacro-iliac  disease  is  well  shown  in  the  accompanying  original  table : 


POTT'S  DISEASE  OF  THE  SPINE. 


247 


COXAIGIA. 

LuuBAR  Pott's  Disease. 

Sacro-iliac  Disease. 

Occurrence, 

Children  under  12  years. 

A  disease  of  childhood. 

Young  adults. 

Pain, 

In  knee  or  hip-joint. 

Referred  to  peripheral  dis- 

Localized  over  sacro-iliac 

tribution  of  lumbar 

joint. 

nerves. 

Limb, 

Apparent     elongation     of 
limb,  adduction  followed 

No  elongation  of  limb. 

Elongation  only  of  limb. 

by  real  shortening. 

1 

Buttocks, 

Early  loss  of   gluteo-fem- 

No  change  in  buttocks. 

No   change    during    early 

oral  fold. 

stage.  Late  obliteration 
of  gluteo-femoral  fold. 

Movements, 

Limited   flexion    and   ex- 

No restriction   of    move- 

No   restriction    of    move- 

tension first  sign. 

ments  in  hip-joifits. 

ments  when  pelvis  is 
fixed. 

Pressure,  

Pressure  on  sides  of  pel- 

Pressure on  sides  of  pel- 

Pressure on  sides   of  pel- 

vis without  pain. 

vis  without  pain. 

vis  causes  severe  pain. 

Deformity, 

Swelling    and    induration 

Angular  median  deformity   Swelling    over    sacro-iliac 

about  trochanter. 

of  lumbar  spine.                     articulation. 

Abscess, *. 

Abscess    sinuses    lead    to 

Abscess    sinuses    lead    to   Abscess    sinuses     lead    to 

hip-joint. 

lumbar  spine. 

1    sacro-iliac  joint. 

Infantile  paralysis  may  be  distinguished  from  the  paraplegia  of  Pott's 
disease  by  the  history,  absence  of  rigidity  or  pain  in  the  vertebral  region,  the 
muscular  weakness  and  atrophy,  and  especially,  in  cases  of  doubt,  by  the  electric 
reactions  in  the  affected  muscles,  the  description  of  which  avlU  be  found  in 
full  in  the  chapter  upon  Infantile  Spinal  Paralysis. 


Progress  and  Prognosis. 

Contrary  to  the  generally  accepted  idea,  many  patients  recover  from  this 
affection,  there  being  a  natural  tendency  thereto.  The  cures  achieved  in  modern 
times  may  justly  be  attributed  to  early  diagnosis,  better  knowledge  of  the  etiology 
and  progress  of  the  disease,  and  the  skilful  adaptation  of  mechanical  measures. 
The  progress  depends  much  upon  the  portion  of  the  spine  affected,  and  will 
be  influenced  by  the  amount  of  personal  attention  and  care  given. 

Although  considering  caries  of  the  spine  to  be  always  a  serious  affection, 
I  do  not,  nevertheless,  deem  life  seriously  imperilled  thereby.  Of  those  who 
receive  proper  care  very  few  perish  directly  from  the  spinal  condition.  Of 
the  hundreds  of  cases  which  I  have  seen,  only  a  very  few  have  died  directly 
from  this  condition,  the  mortality  being  usually  due  to  some  intercurrent  affection 
or  to  the  disease  of  other  organs.  When  unrecognized  or  neglected,  it  becomes 
one  of  the  most  formidable  of  affections — alike  dreaded  by  the  laity  and  shunned 
by  the  profession.  The  percentage  of  mortality  in  269  cases  collected  from 
various  sources  was  found  to  be  about  27.     They  were  as  follows: 


248  ORTHOPEDIC  SURGERY. 

Cases.  Deaths. 

Billroth  and  Menzel, 6i  23 

Jaffe, 82  22 

Mohr, 72  7 

Nebel, 54  18 

269  71 

The  mortality  is  always  much  greater  in  adults  than  in  children. 

The  deformity  may  be  diminished  in  some  cases  by  appropriate  treatment ; 
but  once  present,  it  never  entirely  disappears.  Nothing  renders  the  prognosis 
more  unfavorable  than  the  occurrence  of  abscesses,  especially  when  they  exist 
for  a  long  time  and  discharge  at  a  point  remote  from  the  seat  of  disease.  A 
fortunate  result  is  most  usual,  however,  when  the  abscess  opens  close  to  the 
affected  vertebras,  and  it  has  appeared  to  the  writer  that  such  cases  do  even 
better  than  where  no  abscess  occurs.  A  cure  may  stUl  follow  after  the  abscess 
has  opened  and  discharged  for  a  considerable  period,  but  abscesses  which 
discharge  for  a  long  time  are  a  drain  on  the  vitality  and  a  direct  menace  to 
life,  owing  to  the  ultimate  amyloid  and  other  degenerations  of  the  internal 
viscera. 

A  "  residual  abscess"  may  become  active  at  any,  even  a  remote,  time 
from  the  beginning  of  apparent  cure  of  the  vertebral  lesion. 

The  paraplegia  of  Pott's  disease,  while  a  distressing  and  alarming  complica- 
tion, one  which  materially  lessens  the  prospects  of  cure,  tends,  as  a  rule,  to 
spontaneous  recovery,  the  average  duration  being  a  little  less  than  one  year. 
This  is  well  shown  in  the  analysis  of  58  cases  by  Gibney,  29  of  which  recovered, 
except  one  "still  under  treatment";  again,  Taylor  and  Lovett  report  19  cases, 
of  which  17  recovered,  i  recovered  partially,  and  i  remained  paralyzed;  and 
Sayre  has  reported  38  cases  either  partially  or  completely  paralyzed,  of  which 
34  recovered  and  4  remained  under  treatment.  Relapses  occur,  but  do  not 
materially  affect  the  prognosis.  Exceptions  to  this  favorable  tendency  are  found 
in  the  paralysis  in  connection  with  caries,  which  is  peculiarly  apt  to  end  in 
death;  and  where  sensation  and  motion  are  both  involved  the  restoration  of 
the  power  of  the  limbs  is  only  partial,  or  incurable  paralysis  persists.  Even 
these  cases  are  not  hopeless,  for  cases  of  recovery  after  complete  loss  of  sensation 
have  been  recorded  elsewhere  by  the  writer.  The  spasms  and  contractures 
which  occur  late  in  this  disease  are,  in  my  experience,  usually  permanent. 

A  fatal  issue  may  ensue  from  simple  asthenia,  the  result  of  exces- 
sive suppuration,  hectic  pyemia,  amyloid  degeneration  of  the  internal  viscera, 
intercurrent  affections — tuberculous  or  otherwise — rupture  of  an  abscess  inter- 


POTT'S  DISEASE  OF  THE  SPINE. 


249 


nally,  or  from  hemorrhage  from  perforation  of  a  large  blood-vessel.     An  in- 
teresting case  of  the  latter  is  recorded  by  Ashhurst,  where  a  psoas  abscess 


Fig.  249.— Last  Stage  of  Pott's  Disease,  with  Deopsy.  Fig.  250.— Last  Stage  of  Pott's  Disease,  with  Dropsy. 


caused  ulceration  .and  consequent  rupture  of  a  branch  of  the  internal  iliac 
artery,  leading  to  rapid  death.  It  may  be  safely  said  that  more  children  perish 
from  abscesses  which  open  internally  than  from  all  other  causes  combined. 


250 


ORTHOPEDIC  SURGERY. 


Mohr  found  in  9  cases  of  fatal  abscess  perforation  into  the  esophagus  in  2 ;  pleura 
and  lungs,  in  2;  pleura  alone,  in  i;  peritoneum,  in  i;  and  spinal  canal,  in  2. 
The  prognosis  as  regards  life,  and  the  cause  of  death  in  persons  cured  of  Pott's 
disease,  are  well  shown  in  the  31  specimens  studied  by  Neidert,  at  the  Munich 
Pathological  Institute.  It  was  found  that  persons  with  slight  deformity  have 
as  good  a  chance  of  life  as  normal  individuals ;  persons  with  medium  deformity 
die  young  of  phthisis,  while  persons  with  severe  deformity  die  of  heart-failure 
or  fatigue.  The  average  age  was  forty-nine  and  a  half  years.  Hypertrophy, 
with  or  without  dilatation,  of  the  right  side  will  be  found  to  be  present  in 
the  large  majority  of  individuals  where  deformity  is  present.  In  cervical 
caries  death  as  sudden  as  in  apoplexy  may  result  where  suitable  support  of 


Fig.  251. — Canvas  Frame  for  Treatment  of  Pott's  Disease,  showing  Patient  in  Position. 


the  head  has  been  neglected,  as  in  two  cases  which  I  have  observed  on  two 
occasions. 

The  prognosis  is  more  favorable  in  children  than  in  adult  cases.  The 
tendency  to  cure  is  marked,  varying  with  the  resistance  of  the  individual  and 
the  situation  and  extent  of  the  disease.  Relapses  are  frequent  where  support 
has  been  discontinued  too  early.  Speaking  in  round  numbers,  three  years 
may  be  said  to  be  an  average  time  for  a  course  of  treatment,  and  the  patient 
should  remain  under  observation  from  three  to  ten  years. 

For  years  after  the  full  growth  has  been  attained,  the  exact  height  should 
be  taken  once  a  year,  as  suggested  by  Biggs,  on  the  same  date  of  the  year,  at 
the  same  time,  immediately  after  rising  in  the  morning,  and  under  the  same 
conditions,  the  rod  of  the  machine  resting  upon  the  scalp  in  the  parting  of  the 
hair,  and  any  variation  more  than  3-V  of  ^n  inch  would  be  an  indication  to  con- 
sider the  resumption  of  a  support. 


POTT'S  DISEASE  OF  THE  SPINE. 


251 


Treatment. 

Equipped  with  modern  improved  mechanical  means,  one  approaches  the 
subject  of  treatment  of  spondylitis  with  greater  confidence  than  earlier  writers 
could  possibly  have  done.  In  addition,  practical  surgeons  appreciate  the 
important  role  which  improved  hygiene,  in  its  widest  adaptation,  plays.  In 
considering  this  section  of  the  subject,  the  general  medical  treatment  wUl  be 
considered,  and  only  such  mechanical  measures  as  have  been  found  in  the 
hands  of  the  writer  capable  of  meeting  the  requirements  in  the  majority  of 
cases.  Nature  is  engaged  in  a  local  germicidal  warfare,  and  well-directed 
assistance  may  enable  her  to  conquer. 

The  general  constitutional  treatment  has  already  been  considered  in 
Chapter  II,  Part  I,  tuberculous  joint  disease. 


Fig.  2,2. — Head  Extension  foe.  Pott's  Disease. 


Treatment  by  Recumbency. — Recumbency  as  a  means  of  treatment 
still  has  its  advocates.  Prolonged  recumbency  with  withdrawal  from  sunlight 
and  fresh  air  has  a  deleterious  effect  upon  the  health.  This  form  of  treatment 
should  be  enjoined  during  the  acute  stage,  and  its  evil  effects  may  be  obviated 
by  the  use  of  a  light  iron  frame  covered  with  canvas,  to  which  the  patient  can 
be  accurately  fixed,  with  a  canvas  front  and  straps  and  buckles,  and  which 
permits  of  his  being  lifted  and  carried  about  readUy.  Such  an  oblong  bed 
can  be  constructed,  at  a  moderate  cost,  of  light  gas-pipe  or  stout  steel  bars. 
An  apparatus  of  this  character  permits  also  of  extension,  counter-extension 
and  fixation,  a  method  of  treatment  of  great  advantage  in  cervical  disease. 

The  deformity  should  be  supported  by  small  sand-bags  or  felt  pads  placed 
on  either  side  of  the  kyphosis,  and  direct  corrective  pressure  should  be  made 
by  means  of  a  bent  bed-frame,  the  angle  of  the  support  being  aided  by  the 


252 


ORTHOPEDIC  SURGERY. 


weight  of  the  body  above  and  below  the  seat  of  the  disease.  The  advantages 
of  recumbency  may  be  greatly  increased  by  the  employment  of  a  special  wheel 
couch  in  which  the  patient  may  be  carried  into  the  fresh  air  and  sunshine. 
Of  these  there  are  many  different  forms.  The  one  employed  by  the  writer 
is  shown  in  Fig.  135,  page  149. 

Wliile  in  the  recumbent  position  traction  upon  the  spine  should  be  made, 
in  cervical  and  dorsal  cases,  by  a  head  extension,  of  which  there  are  many 


Fig.  253. — Head  Extension  for  Cervical  Caries. 


forms  in  use;  and  in  lumbar  disease  the  traction  should  be  made  by  adhesive 
plaster  extension  applied  to  the  lower  extremities.  In  severe  forms  of  disease 
traction  may  be  made  from  both  ends  at  the  same  time.  If  the  patient  is  restless 
or  unruly  at  night,  and  straps  and  buckles  are  not  used,  the  patient  may  be 
prevented  from  sitting  up  by  a  crib-net,  which  is  securely  fastened  to  the  four 
posts  and  top  rail  of  the  crib. 

In  small  children  an  exact  has  relief  of  the  body  may  be  made  with  a  plaster- 
of-Paris  bandage  applied  to  the  back,  or  cream  plaster  poured  upon  stockinet, 


POTT'S  DISEASE  OF  THE  SPINE. 


253 


with  the  patient  in  the  supine  position.     After  it  has  hardened  and  been  trimmed 
it  makes  an  excellent  fixation  apparatus. 

Treatment  by  Suspension. — Suspension  as  a  mode  of  treatment  is  an 
old  plan  which  has  recently  been  brought  into  prominence;  it  was  employed 
as  early  as  1826  by  Prof.  J.  K.  Mitchell,  of  Philadelphia.  Independent  of 
support,  as  a  remedial  agent  in  uncomplicated  cases,  it  has  no  special  value. 
In  paraplegia  it  is  of  distinct  advantage,  and  will  be  described  under  the  treat- 
ment of  this  complication. 

Complete  suspension  can  only  be  employed  temporarily  in  securing  a 

better  position  of  the  trunk  for  the  application 
of  plaster-of-Paris  or  other  fixative  apparatus, 
and  great  care  should  always  be  exercised 
therein.     It  is  now  recognized  that  the  de- 


FiG.  254. — Patient  Suspended  Ready  for 
THE  Plaster  (Stimson). 


Fig.  255. — Door  Suspension  for  Plaster  Jackets. 


formity  itself  cannot  be  changed  by  the  weight  of  the  body  alone.  The  vertebral 
column  above  and  below  the  gibbosity  may  be  extended  and  straightened,  but 
the  diseased  area  remains  fixed.  In  fact,  attempts  to  accomplish  correction 
by  complete  suspension  have  been  followed  by  immediate  paraplegia  and  death. 

Mechanical  Treatment. — The  machines  and  appliances  employed  are 
innumerable,  but  can  all  be  classed  in  two  groups:  (i)  The  fixed  jacket  of 
plaster-of-Paris,  and  its  modifications  in  silicate  of  soda,  poroplastic  felt,  leather, 
woven  wire,  paper,  bamboo,  wood,  etc. ;   (2)  the  spine  brace. 

The  plaster-of-Paris  jacket  filled  a  long-felt  want,  and  its  various  modifica- 


254 


ORTHOPEDIC  SURGERY. 


tions  have  extended  the  range  of  its  usefulness.  When  the  patient  is  suspended 
by  the  neck,  the  rope  should  never  be  tied,  but  should  be  held  by  an  assistant, 
as  an  accident  or  even  a  fatal  result  might  occur  in  this  manner.  The  technic 
of  its  application  is  so  well  known  that  it  need  not  be  dwelt  upon  here,  but 
the  method  as  now  employed  must  be  briefly  described.  The  best  material 
for  the  rollers  will  be  found  to  be  fine  plaster,  kept  thoroughly  dried,  and  cheese- 
cloth or  butter-cloth.  Stockinet  in  different  sizes  is  more  convenient  than 
the  knit  shirts  formerly  employed,  or  an  ordinary  sleeveless  woven  shirt  answers 
very  well.     In  either  case  the  garment  must  be  a  tight  fit.     The  breasts  must 

be  protected  with  cotton,  and  in  some  cases  a 
folded  towel  may  be  placed  over  the  epigastrium 
as  a  "dinner  pad,"  to  be  subsequently  removed. 
A  piece  of  felt  is  placed  on  either  side  of  the 
deformity  and  also  over  the  crest  of  the  ilium  of 
each  side.  The  patient  is  to  be  suspended  until 
only  the  toes  touch  the  floor,  and  the  bandages, 
thoroughly  wetted  by  placing  singly  on  end  in 
warm  water  until  the  air-bubbles  cease  to  rise 
from  the  submerged  bandage,  and  squeezed  nearly 
dry,  are  to  be  applied  quickly  from  below  upward 
and  well  rubbed  between  each  layer.  In  this 
manner  a  thin,  neat,  and  strong  cast  should  be 
obtained.  The  cast  should  be  worked  in  above 
the  crest  of  the  ilium  so  as  to  give  better  shape 
and  support.  As  soon  as  this  is  completed,  the 
patient  should  be  carefully  placed  in  a  recum- 
bent position  until  the  plaster  has  set,  when  the 
front  should  be  cut  down,  the  armholes  trimmed, 
and  the  corset  be  bound  and  have  the  lace-hooks  adjusted. 

While  possessing  certain  advantages  of  economy,  requiring  less  special 
experience  in  its  application,  and  being  entirely  beyond  the  control  of  the  patient 
or  attendants,  there  are  certain  positive  disadvantages — the  encircling  of  the 
body  within  a  solid  support;  the  inability  to  inspect  the  condition  of  the  skin 
and  note  the  progress  of  the  affection ;  the  formation  of  excoriations,  ulcerations, 
and  abscesses  without  the  knowledge  of  the  surgeon ;  the  lack  of  cleanliness, 
etc. — which  relegate  it  and  its  modifications  to  a  secondary  position.  When 
split,  furnished  with  lacings,  and  applied  and  removed  at  will,  it  loses  part 


Fig.  256. — Felt  Jacket  of  Beely 
(Schreiber). 


POTT'S  DISEASE  OF  THE  SPINE.  255 

of  its  efficiency,  but  there  is  a  gain  in  comfort  and  cleanliness.  It  is  of  decided 
value,  however,  for  patients  who  are  unable  to  bear  the  expense  of  even  the 
cheapest  apparatus;  in  such  cases,  with  attention  to  detail,  a  cure  may  often 
be  effected,  and  the  writer  has  in  public  practice  frequently  proved  this  state- 
ment, especially  when  the  disease  was  located  in  the  lumbar  region.  In  all 
cases  of  disease  above  the  seventh  dorsal  vertebra,  a  chin-rest  should  be  added 
to  remove  the  superincumbent  weight,  and  more  particularly  to  extend  and  fix 
the  diseased  area.  The  "jury-mast"  is  the  head-piece  generally  employed 
with  the  plaster  jacket,  but  is  open  to  the  objection  that,  while  it  supports, 
it  does  not  fix  the  head.  This  may  be  accomplished  by  attaching  it  to  two 
uprights  fitted  to  the  back  of  the  head;  or,  better,  by  the  use  of  the  chin-rest, 
to  be  described  later  under  the  spine  brace. 

In  justice  to  this  mode  of  treatment,  it  must  be  added  that  there  are  certain 
cases  in  which  it  is  the  best  and  most  efficient;  this  applies  particularly  to  the 
lateral  deviation  of  the  spinal  column  present  in  certain  cases  of  Pott's  disease 
and  in  lower  lumbar  disease. 

Correction  of  the  Deformity. 

Gradual  Reduction. — At  the  present  time  there  are  several  methods 
which  aim  at  the  gradual  correction  of  the  deformity  by  the  employment  of 
traction  and  pressure.  The  methods  employed  by  Goldthwait,  Taylor,  Redard, 
and  Schede  are  all  upon  the  same  principle  and  have  all  been  followed  by  very 
satisfactory  results.  The  different  methods  are  so  well  shown  in  the  illustrations 
that  it  is  not  necessary  to  describe  them  in  detail  here. 

The  leather  corsets  are  prepared,  over  a  counter-cast  from  the  plaster- 
of-Paris  jacket,  from  rawhide,  untanned  leather,  or  saddler's  skirting.  As 
manufactured  by  surgical-instrument  makers  they  are  ornate  and  durable, 
but  entirely  satisfactory  leather  jackets  can  be  made  by  any  practitioner.  The 
adjustable  wooden  corset  is  more  difficult  to  manufacture,  but  may  be  made 
by  almost  any  one  by  attention  to  the  details  as  given  by  the  writer  elsewhere  in 
the  section  on  General  Orthopedics  and  as  shown  in  the  illustrations.  It  consists 
essentially  of  a  wooden  cuirass  manufactured  somewhat  similarly  to  the  felt 
and  leather  jackets,  and  composed  of  alternate  layers  of  stockinet,  wood,  roller 
bandage,  and  linen,  held  intimately  together  with  glue. 

Spine  Braces. — The  spine  brace  should  act  on  the  principle  of  a  lever, 
the  fulcrum  being  the  diseased  part  of  the  spinal  column,  the  weight  at  the 
waist-band,  and  the  power  applied  above  to  pull  the  part  above  the  kyphosis 


256 


ORTHOPEDIC  SURGERY. 


back  as  far  as  possible.  The  writer  has  personally  had  the  best  results  with 
the  antero-posterior  support  known  as  the  Taylor  spine  brace,  an  apparatus 
constructed  upon  this  principle.  It  consists  of  a  pelvic  band,  upon  which 
are  attached  two  uprights  of  the  best  annealed  steel,  admitting  of  easy  manipula- 


FlG.    257. — GOLDTHWAIT   EXTENSION   FRAME. 

a,  Bar  suspended  from  gas-pipe  frame;  6,  vertical  rod;  c,  cross-bar;  d,  malleable  steel  bars. 

tion  and  bending,  connected  with  two  transverse  bars  from  which  arise  two 
shoulder-pieces.  These  uprights  are  separated  sufhciently  to  rest,  when  applied, 
upon  the  transverse  processes  throughout  the  greater  part  of  the  spinal  column 


Fig.  258.— Goldthwait  Extension  Frame  with  Patient  in  Position. 

and  at  the  seat  of  deformity;  extending  some  distance  above  and  below  are 
the~pad  plates;  the  latter  are  pieces  of  softer  steel  fastened  to  the  uprights  by 
hinges  and  screws,  admitting  of  ready  removal  and  bending,  and  best  covered 
with  hard-rubber  or  ground  cork  inclosed  in  canton  flannel.     The  shoulder- 


POTT'S  DISEASE  OF  THE  SPINE. 


257 


pieces  are  provided  with  covered  webbing  straps,  and  the  transverse  bars  and 
pelvic  band  with  buckles.     The  apparatus  is  securely  held    in    position ^by 


Fig.  259. — Apparatus  for  Forcible  Correction  in  Pott's  Disease  (Redard). 


Fig.  260. — Same    showing  Application  (Redard). 


Fig.  261. — Same,  showing  Pressure  Pads. 


an  apron  of  stout  muslin  and  webbing  straps.     The  patient  is  placed  prone 
upon  a  hard  couch  and  the  measurements  are  taken  with  a  lead  strip,  carefully 

IS 


25S 


ORTHOPEDIC  SURGERY. 


molded  to  the  inequalities  of  the  transverse  processes,  from  the  anal  fissure 
below  to  the  upper  border  of  the  scapula  above.  This  outline,  carefully  traced 
upon  stiff  cardboard,  is  cut  out,  and  serves  both  as  a  plan  for  the  manufacture 
of  the  instrument  and  a  record  for  subsequent  reference.  The  pelvic  band 
is  measured  from  one  trochanter  to  the  other.  The  upper  parts  of  the  uprights 
are  bent  backward,  so  as  not  to  rest  upon  the  surface  when  applied  in  the  recum- 
bent position,  but  make  gentle  traction  backward.     The  brace  should  always 

be  applied  in  the  recumbent  posture,  the 
pelvic  band  be  secured  first,  the  axillary 
straps  next,  to  the  lower  transverse  bar, 
and,  thirdly,  the  upper  apron-strap  to  the 
buckles  of  the  upper  transverse  bar.  The 
middle  straps  of  the  apron  are  then  secured 
over  the  uprights  by  means  of  safety-pins. 
In  some  cases  of  lumbar  caries  a  swathe  of 
plaster-of-Paris  bandage,  muslin,  leather,  felt, 
or  celluloid  will  add  much  to  the  comfort  of 
the  patient  and  increase  the  degree  of  fixation 


Fig.  262. — Spine  Brace  foe  Cervical 
Caries,  showing  Head  Extension  and 
Felt  Front. 


Fig.  263. — Chest-piece  for  Spinal  Support  (Taylor). 


and  pressure.  Much  ingenuity  and  variety  may  be  displayed  in  the  matter  of 
pelvic  bands,  shoulder-straps,  aprons,  etc.,  but  the  principle  of  all  is  the  same. 
Great  care  must  be  observed  to  so  regulate  the  pressure  on  either  side  of  the 
deformity  as  to  secure  fixation  of  the  inflamed  area  without  undue  pressure. 

The  apparatus  may  be  considered  as  having  reached  the  limit  of  its  efficiency 
if  it  makes  the  greatest  possible  pressure  on  the  projection  compatible  with 
comfort  and  integrity  of  the  skin. 


1 

^^^^^^  "" 

H 

^^r        ''^ 

^Isif 

1 

^^^^^k'>  -  ^^if 

j 

1 

Fig.    264. — Spine    Brace    for    Dorsolumbar 
Caries. 


Fig.  265. — Taylor  Spine  Brace  with  CniN-REST.' 


Fig.  266. — Taylor  Spine  Br.^ce. 


Fig.  267. — .A.PPARATUS  with  Chin-rest 
for  Pott's  Dise.ase. 

a.  Chin-rest;  h,  support;  c,  upright  for 
chin-rest;  d,  upper  bar;  e,  a.xillary 
crutches;  /,  uprights;  h,  pelvic  band. 


POTT'S  DISEASE  OF  THE  SPINE. 


261 


The  apparatus  must  be  worn  day  and  night,  unless  some  special 
complication  calls  for  its  removal,  and  under  no  circumstances  should  the 
patient  assume  the  upright  position  without  the  support.  In  all  cases  where 
the  disease  is  above  the  seventh  cervical  vertebra  the  apparatus  must  be 
supplemented  by  a  chin-rest,  to  fix  the  diseased  area  and  support  the 
superincumbent  weight;   this  consists  of  an  ovoid  steel  ring,  made  to  open 

on  the  side  and  secured  when  closed, 
arranged  so  that  it  can  support  the  skin 
in  a  hard-rubber  cup  and  exert  pres- 
sure upon  the  occiput,  and  attached  to 


■R 

S^ 

H^l 

Wr 

w 

WJ 

^h. 

ji 

^^^KkP^'^i 

^m^ 

s#% 

IL. 

„^_ 

Fig.    268. — Spine   Brace   for   Dorsal   Pott's 
Disease. 


Fig.  269. — Apparatus  for  Cervical  Caries— Cazix 
AND  Lannelongue  (Redard). 


the  steel  upright  by  a  ball-and-socket  joint,  which  allows  of  motion  in  all 
directions  or  can  be  fixed  at  any  point.  The  head  is  secured  by  a  webbing 
strap  passing  about  the  forehead  from  the  extremities  of  the  posterior  uprights. 
In  those  cases  before  spoken  of,  where  lateral  deviation  complicates  the 
disease,  it  will  be  necessary  to  bend  the  brace  up  on  one  side  and  down  on  the 
other,  and  by  enforced  recumbency  await  the  subsidence  of  the  muscular  spasm 
— or,  removing  the  apparatus,  apply  a  well-fitting  plaster  jacket  with  suspension. 


262 


ORTHOPEDIC  SURGERY. 


and  subsequently  resume  the  use  of  the  spine  brace.  In  cervical  cases  the 
Goldthwait  modification  has  proved  efiicient  in  my  hands.  The  brace  and 
head-piece  are  all  in  one  piece,  the  latter  being  an  extension  upward  of  the 
spinal  uprights. 

Treatment  of  Caries. — When  it  is  possible,  efforts  should  be  made  to 
remove  portions  of  the  diseased  vertebras  through  incisions  made  for  the  escape 
of  pus  or  by  enlarging  old  sinuses.  In  the  cervical  region  the  bodies  of  the 
vertebras  may  sometimes  be  reached  by  an  incision  along  the  posterior  border 


Fig.  270. — Antero-posterior  Support  with 
Straight  Band  and  Plaster-of-Paris 
Swathe. 


Fig.  271. — Antero-posterior  Spine  Brace,  with 
Chin-rest. 


of  the  sternomastoid.  An  incision  may  also  be  made  in  the  back  of  the  neck. 
These  incisions  should  follow  the  course  of  sinuses  or  should  be  at  those 
points  from  which  the  seat  of  the  disease  is  most  readily  accessible.  The  dis- 
eased bone  should  be  removed  with  a  curet  as  thoroughly  as  possible,  great 
care  being  taken  not  to  injure  important  structures.  In  the  dorsal  region  the 
bodies  cannot  be  reached  unless  the  transverse  processes  and  a  portion  of  the 
rib  are  excised.  This  should  be  done  if  they  are  diseased,  but  such  an  opera- 
tion is  not  advisable  unless  caries  is  present.     The  bodies  of  the  vertebras  may 


POTT'S  DISEASE  OF  THE  SPINE. 


263 


be  cureted,  and  in  exceptional  cases  a  drainage-tube  may  be  passed  around  the 
front  part  of  the  vertebra.  An  operation  of  this  nature,  at  which  I  assisted, 
was  not  of  very  great  benefit. 

In  the  lumbar  region  an  incision  should  be  made  from  the  twelfth  rib 
to  the  ilium,  beginning  2|  inches  to  the  outside  of  the  spinous  processes.  The 
dissection  is  then  carried  carefully  down  until  the  psoas  is  reached,  when,  some 
fibers  of  this  muscle  being  carefully  detached  from  the  transverse  process, 
the  anterior  surface  of  the  vertebra  becomes  accessible  and  portions  of  it  may 
be  removed.  This  operation  is  sometimes  spoken  of  as  Treves'  operation. 
It  is  a  satisfactory  operation,  and  in  performing  it  I  have 
been  able  to  reach  almost  the  entire  surface  of  the  bodies 
of  the  vertebras. 

The  two  most  frequent  complications — abscess  and 
paraplegia — require  special  treatment. 

The  Treatment  of  Abscesses  (Expectant). — Iliac, 
lumbar,  and  psoas  abscesses  are  formidable  complica- 
tions. It  has  been  the  habit  of  surgeons  to  treat  these 
expectantly — to  allow  them  to  open  spontaneously.  Where 
the  abscess  is  small,  stationary,  and  does  not  make  pres- 
sure upon  important  organs,  it  will  frequently  be  absorbed 
by  fixation  and  recumbency. 

Operative  Methods. — Evacuation  and  hyperdisten- 
tion  of  the  cavity  with  various  antiseptic  fluids  have  been 
practised  by  a  number  of  surgeons;  but  the  operation- 
did  not  fulfil  all  that  was  anticipated,  and  Demours  and 
Demoulin,  and  Bradford  and  Lovett,  have  each  recorded 
a  death  from  it — two  in  all. 

Under  strict  aseptic  precautions  the  dangers  of  septicemia  are  greatly 
lessened,  and  in  suitable  cases — where  the  pressure  effects  and  distention  of 
the  abscess  demand  urgent  interference — free  incisions,  openings,  and  counter- 
openings,  with  insertion  of  drainage-tubes,  should  be  advocated;  particularly 
is  this  best  where  from  the  location  and  size  it  appears  possible  to  remove  by 
cureting  the  entire  pyogenic  membrane. 

In  retropharyngeal  abscess  and  deep  cervical  abscesses  burrowing  toward 
the  chest  prompt  surgical  measures  must  be  adopted.  The  former  can  be 
relieved  by  a  guarded  bistoury,  or  in  some  cases  by  the  administration  of  an 
emetic;    the  incision  should  be  made  in  the  median  line  of  the  posterior  wall 


;g.  272. — Goldthwait's 
Modification  of  Tay- 
lor's Brace  (Bradford 
and  Lovett). 


264 


ORTHOPEDIC  SURGERY. 


of  the  pharynx,  and  the  head  quickly  thrown  forward  to  avoid  suffocation 
or,  what  is  decidedly  better,  the  "Roser  position,"  as  recommended  by  Burrell, 
of  Boston,  with  the  head  dependent  over  the  end  of  the  table,  with  a  suitable 
mouth-gag.  In  this  manner  one  does  not  have  to  make  a  plunge  in  the  dark, 
but  the  apex  of  the  abscess  can  be  freely  incised,  and  a  free  discharge  of  pus 
will  take  place  through  the  mouth  and  nostrils.  In  deep  cervical  abscesses 
which  are  approaching  the  thorax  along  the  deep  cervical  fascia,  the  plan  of 
Mr.  Hilton  is  best  adopted.  An  incision  should  be  made  through  the 
sternomastoid,  an  exploratory  incision  carried 
through  the  deep  fascia,  and  if  pus  be  found, 
the  incision  further  extended. 

In  psoas  and  lumbar  abscess  through-and- 
through  drainage  should  be  established  where  pos- 
sible, and  in  iliac  abscess  a  portion  of  the  rim  of  the 
ilium  may  with  advantage  be  removed  by  bone  for- 
ceps or  trephine  to  permit  thorough  drainage. 


Fig.  273. — Lumbar  Abscess,  showing  Cicatrix. 


Fig.  274. — Intern.\l  Lumbar 
Abscess,  showing  Primary 
AND  Counter  Incisions. 


Operative  Methods. — The  operation  advocated  in  these  cases  is 
performed  under  strict  aseptic  precautions.  The  abscess  is  opened  by  careful 
dissection,  the  incision  being  made  in  the  direction  of  Poupart's  ligament, 
half  an  inch  to  the  inner  side  of  the  anterior  superior  spinous  process.  The 
external  oblique  muscle  is  divided  in  the  direction  of  its  fibers,  and  the  internal 
oblique  at  right  angles,  or  the  fibers  are  separated.  The  contents  of  the  sac 
are  evacuated,  and  a  long,  heavy,  grooved  director  or  eye  probe  is  carefully 


POTT'S  DISEASE  OF  THE  SPINE. 


265 


passed  up  to  a  point  above  the  sacro-iliac  junction,  and  a  straiglit  longitudinal 
incision  made  upon  it.  The  counter-incision  in  two  of  the  cases  reported  was 
half  an  inch  to  the  outer  side,  above  the  posterior  superior  spinous  processes 
of  the  ilium.  In  one  case,  in  which  I  was  associated  with  Drs.  Willard  and 
Ashhurst,  it  was  considered  advisable  to  remove  a  portion  of  the  crest  of  the 
ilium  with  a  rongeur  forceps,  so  as  to  permit  the  drainage-tube  to  lie  fiat  in  the 
iliac  fossa.  This  appeared  to  facilitate  the  drainage  and  healing  of  the  abscesses 
rather  than  to  retard  them. 

The  abscess  cavity  is  thoroughly  irrigated  with  sterUized  water  and  boric- 
acid  solution.     A  rubber  drainage-tube  is  passed  through  it  and  secured  by 


'■® Y 


Fig.  275. — Diagram  Illustrating  Position  of 
Incision  in  Lumbar  Abscess. 


Fig.     276. — Diagram     showing    Position 
Counter  Incision  in  Lumbar  Abscess. 


safety-pins.  This  is  allowed  to  remain  in  place  for  two  or  three  days,  after 
which  it  is  gradually  shortened.  Half  an  ounce  of  a  10  per  cent,  emulsion 
of  iodoform  is  introduced  into  the  cavity,  iodoform  gauze  packed  about  the 
wound,  and  a  bichlorid  dressing  applied. 

The  indications  for  this  operation  are:  (i)  When  the  abscess  is  large 
and  makes  pressure  upon  important  organs.  (2)  When  the  abscess 
is  increasing  rapidly  in  size.  (3)  When  there  is  danger  of  rupture  of 
the  abscess  into  the  peritoneal  cavity.  In  the  case  of  a  psoas  or  gluteal 
abscess  it  is  rarely  possible  to  make  a  counter-opening,  and  to  accomplish 
through-and-through  drainage  a  rubber  drainage-tube  should  be  inserted 
into   the   cavity  as   far    as    possible,  and   the  cavity  irrigated  daily  or  every 


266  ORTHOPEDIC  SURGERY. 

Other  day  with  boiled  water  and  boric  acid  solution,  followed  by  the  use  of 
the  iodoform  emulsion. 

I  have  performed  this  operation  many  times  and  have  never  experienced 
any  accidents,  except  upon  one  occasion,  when  in  a  case  of  psoas  abscess  while 
making  the  counter  incision  I  opened  the  pleural  cavity.  This  was  immediately 
closed,  and  an  opening  made  lower  down,  and  the  recovery  was  uneventful. 
\\Tien  the  abscess  is  not  opened  early  and  burrows  beneath  Poupart's  ligament 
and  opens  on  the  front  of  the  thigh,  or  gravitates  backward  on  the  thigh,  it 
is  necessary  to  make  through-and-through  drainage  at  this  point  also.  In 
cases  of  this  kind  I  have  devised  an  original  method  of  closing  off  the  lower 
abscess  by  separate  tubes  and  packing,  and  establishing  through-and-through 
drainage  at  the  points  just  indicated  in  the  foregoing  operation. 

Before  the  abscess  has  advanced  far  enough  to  appear  as  a  swelling  in 
the  groin,  but  still  forms  a  sausage-like  mass  in  the  iliac  fossa,  it  may  some- 
times be  opened  by  a  posterior  incision.  This  incision  should  be  parallel  with 
the  lumbar  vertebras  and  divide  the  quadratus  lumborum  muscle  until  the 
sac  is  reached.  The  sac  may  be  made  tense  by  pressure  on  the  groin.  ^ly 
experience  with  this  operation  has  been  satisfactory,  but  I  should  always  consider 
through-and-through  drainage  more  thorough. 

In  all  abscesses,  after  thorough  cleansing  with  antiseptic  solutions,  a  lo  per 
cent,  emulsion  of  iodoform  in  oil  should  be  injected,  and  a  full  aseptic  dressing 
employed.  A  proper  fixation  apparatus  will  add  much  to  the  efficiency  of  any 
form  of  local  treatment.  I  have  myself  seen  a  case  of  cervical  caries,  under 
the  care  of  another  surgeon,  in  which  the  fatal  result  could  have  been  directly 
attributed  to  septic  infection. 

The  Treatment  of  Paraplegia. — The  management  of  paraplegia  consists 
in  recumbency,  the  accurate  application  of  a  spinal  support,  suspension,  internal 
medication,  and  in  advanced  stages  the  employment  of  forcible  correction 
or  laminectomy. 

Recumbency:  The  discovery  of  slight  loss  of  motor  power  with 
exaggerated  knee-reflex  is  the  signal  for  recumbency.  AH  those  methods 
previously  described  under  this  subject  should  be  employed. 

Apparatus:  Whatever  form  of  apparatus  is  used  it  should  be  most 
thoroughly  fitted.  If  the  disease  be  in  the  cervical  region,  the  body  and  head 
portion  should  be  so  made  as  not  to  permit  of  lateral  motion.  For  this  purpose 
I  have  had  the  best  results  from  the  use  of  a  felt  cuirass  inclosing  the  body, 
neck,  and  head.     This  is  made  over  a  counter-cast  which  has  been  made  from 


POTT'S  DISEASE  OF  THE  SPINE. 


267 


a  plaster  cast  of  these  regions  taken  with  the  patient  in  the  prone  position. 

In  upper  dorsal  disease  the  neck  should  also  be  fixed,  and  in  the  lower  dorsal 

and  lumbar  regions  the  apparatus  should  be  carried  as  high  as  possible  on 

the  shoulders,  and  the  scapulas  be  held  by  pressure  pads. 

Suspension:  When  the  paralysis  has  advanced  to  the  loss  of  sensation, 
benefit  may  be  derived  from  vertical  suspension,  as 
apphed  by  Charcot,  Mitchell,  Wood,  and  others. 
The  suspension  should  be  carried  out  daUy  for  from 
ten  to  twenty  minutes.  This  form  of  suspension  is 
most  useful  in  the  treatment  of  adult  patients,  since 


Fig.  277. — Felt  Spinal  Cui-      Fig.''2  7S. — Spi.xe   Brace  with  Paralysis   Braces   for  Spastic  Con- 
EASS  FOR  Pott's  Disease.  '  traction  from  Pott's  Disease. 


the  introduction  of  the  horizontal  backward  extension  by  means  of  the  bent 
tray  has  been  found  satisfactory  in  the  treatment  of  children. 

In  connection  wdth  suspension  the  application  of  heat  and  cold  alternately 
to  the  spine,  as  introduced  by  S.  Weir  jNIitchell,  will  be  found  of  signal  service 
where  there  is  complete  loss  of  sensation.     Hot  compresses  are  applied  over 


268 


ORTHOPEDIC  SURGERY. 


the  deformity  for  from  three  to  five  minutes,  after  which  the  part  is  rubbed 
with  ice  for  the  same  length  of  time,  each  application  being  repeated  twice. 
The  effect  upon  the  circulation  of  the  spine  through  the  application  of  heat 
and  cold  aids  in  the  absorption  of  the  edema  and  is  frequently  followed  by 
marked  improvement.  Manual  massage  of  the  limbs  and  spine  is  not  beneficial 
until  after  sensation  has  returned,  and  electricity  is  contraindicated  in  the 
earlier  stages  while  spasm  exists,  but  in  the  later  stages  seems  to  hasten  the 
recovery. 

Medical  Treatment:  The  medical  remedies  which  are  used  for 
tuberculous  affections  in  other  parts  of  the  body  are 
of  equal  benefit  in  the  treatment  of  paraplegia,  and 
there  are  certain  drugs  which  are  especially  valuable. 
The  use  of  large  doses  of  potassium  iodid  is  often  found 
extremely  satisfactory,  and  the  best  method  of  taking 
this  is  in  liquid  pepsin.  The  dose  should  at  first  be 
from  five  to  ten  grains  three  times  a  day,  this  being 
gradually  increased  until  from  twenty  to  sLxty  grains 
are  taken  thrice  daily.  The  internal  administration 
of  mercury  in  the  form  of  bichlorid  combined  with 
potassium  bromid  will  be  found  useful,  and  may 
be  alternated  with  the  potassium  iodid.  The  use 
of  strychnin  has  been  condemned  by  most  observers 
in  the  treatment  of  paraplegia,  and  is  contrain- 
dicated when  there  is  muscular  spasm.  It  is,  how- 
ever, distinctly  advantageous  when  there  is  pain 
of  a  neuralgic  character  and  when  the  muscular 
spasm  is  not  great.  The  doses  should  be  moderate, 
yio-  to  J-fj-  of  a  grain  being  given  three  times  daily. 

Patients  should  not  be  placed  upon  their  feet  too  early  after  the  return 
of  motor  power.  The  reappearance  of  ankle-clonus  at  any  time  during  the 
course  of  the  recovery  would  be  an  indication  that  the  patient  should  be  directed 
to  resume  the  horizontal  position,  and  the  upright  position  should  never  be 
assumed  untU  the  ankle-clonus  has  entirely  disappeared.  The  first  efforts 
at  walking  may  be  assisted  by  a  suspension  apparatus,  but  crutches  are  not 
to  be  recommended,  particularly  in  dorsal  deformity,  on  account  of  the  mobility 
of  the  scapula. 

The  eft'ect  of  a  change  of  climate  upon  the  paralysis  is  variable,  some 


Fig.  279. — Suspension  for 
I  Paralysis  in  Pott's  Dis- 
.'    ease. 


POTT'S  DISEASE  OF  THE  SPINE.  269 

patients  being  greatly  benefited  while  others  appear  to  derive  no  benefit  whatever 
from  this  method  of  treatment.  A  sojourn  at  the  seashore  is  sometimes  of 
advantage  when  the  paralysis  is  due  to  an  abscess  pressing  upon  the  cord ;  and 
under  the  influence  of  the  salt  air,  there  is  frequently  a  disappearance  of  the 
paralysis,  resulting  from  the  absorption  of  the  pus,  the  shrinking  of  the  abscess 
sac,  and  the  generally  improved  condition  of  the  patient.  Where  the  paralysis 
is  due  to  other  causes,  as  a  tuberculous  mass  or  bony  pressure  upon  the  cord, 
the  seashore  does  not  appear  to  be  of  any  particular  value,  and  a  change  to  the 
country  or  mountains  is  preferable. 

Forcible  Correction:  In  order  to  remove  the  unsightly  deformity  caused 
by  this  disease  the  forcible  correction  described  by  such  ancient  writers  as 
Hippocrates  and  Pare  was  revived  by  Chipault  in  1895,  and  more  recently 
popularized  by  Calot,  in  1896.  The  operation  as  performed  by  him  consisted 
in  direct  manual  traction  upon  the  deformity,  and  the  reduction  of  the  kyphosis 
by  manual  pressure,  the  amount  of  traction  being  estimated  at  from  60  to  160 
pounds,  and  the  pressure  from  30  to  80  pounds.  He  reported  204  patients 
operated  upon,  with  two  deaths  within  two  days  and  three  deaths  at  a  period 
subsequent  to  the  operation.  Partial  paralysis  followed  in  one  case,  and  in 
another  case  an  abscess  developed  shortly  after  the  operation. 

As  a  substitute  for  laminectomy  the  operation  of  forcible  correction  for 
paraplegia  has  a  place  in  surgery  in  selected  cases,  and  is  particularly  adaptable 
when  the  deformity  is  in  the  dorso-lumbar  lower  or  middle  dorsal  region,  but 
it  is  seldom  required  for  deformity  in  the  other  parts  of  the  spine.  The  cases 
which  are  most  suitable  are  those  in  which  the  disease  has  not  been  of 
very  long  duration  and  in  which  the  consolidation  has  not  advanced  to  bony 
ankylosis.  The  presence  of  large  abscesses  is  a  contraindication.  If  the 
paralysis  has  existed  for  a  year  without  any  improvement  under  medical  and 
mechanical  treatment,  forcible  correction  may  be  performed  under  an  anesthetic, 
with  the  probability  of  benefiting  this  complication.  The  amount  of  force 
required  is  not  so  great  as  was  recommended  by  Calot,  as  by  using  less  violent 
measures  the  danger  of  dartiage  to  the  surrounding  structures  may  be  avoided. 
The  amount  of  force  required  should  be  determined  by  the  yielding  of  the 
deformity,  and  two  or  more  trials  may  be  made  before  finally  resorting  to 
laminectomy. 

In  performing  the  operation  of  forcible  correction  the  patient  is  prepared 
as  for  the  application  of  a  plaster-of-Paris  jacket,  in  the  prone  position.  An 
anesthetic  is  administered  and  the  patient  placed  with  the  face  down  upon 


270  ORTHOPEDIC  SURGERY. 

a  firm  table.  Traction  is  made  upon  the  head  by  means  of  a  bandage  or  leather 
head  support,  and  upon  each  extrenxity  by  the  hands  of  assistants,  there  being 
five  thus  employed.  Gentle  downward  pressure  is  made  upon  the  deformity 
by  the  right  hand  of  the  surgeon,  while  the  left  hand  is  placed  beneath  the  body, 
the  deformity  gradually  yielding,  and  the  adhesions  being  broken.  Felt  pads 
are  placed  on  either  side  of  the  deformity  over  the  crests  of  the  ilium,  and  a 
pad  is  placed  over  the  epigastrium.  Extension  is  maintained  while  plaster- 
of-Paris  bandages  are  applied,  and  the  cast  is  carried  low  over  the  pelvis,  and 
includes  the  neck  and  head.  Some  surgeons  use  steel  apparatus  in  addition 
to  the  plaster  jacket.  The  cast  should  be  worn  for  from  four  to  six  months, 
and  the  recumbent  position  should  be  maintained  for  from  eight  to  twelve 
months. 

The  revival  of  this  operation  was  signalized  by  the  performance  of  a  large 
number  by  many  operators.  The  results  of  the  operation  have  been  carefully 
analyzed  by  Bradford  and  Cotton.  They  reported  699  operations  by  34  opera- 
tors. Of  these,  there  were  25  deaths  from  all  causes,  five  of  which  were  attributed 
to  the  effect  of  the  operation  and  the  use  of  chloroform.  In  23  where  the 
paralysis  was  present  before  the  operation,  17  were  relieved,  2  were  not  relieved, 
and  I  was  made  worse;  and  in  four  instances  the  paralysis  appeared  after 
the  correction.  The  direct  effect  upon  the  deformity  by  this  operation  in  224 
cases  was  complete  correction  in  130,  and  incomplete  in  194.  The  total  result 
in  77  cases  gave:  some  relapses  in  50  cases,  no  relapses  in  20,  and  total  relapse 
in  7.  Relapses  may  be  attributed  to  too  short  a  period  of  recumbency  or  to 
ineffective  mobilization. 

The  experience  which  I  have  had  in  this  operation  leads  me  to  consider 
it  an  unnecessarily  severe  procedure,  and  one  liable  to  be  followed  by  general 
tuberculosis,  tubercular  meningitis,  paraplegia,  abscess,  rupture  of  abscesses, 
rupture  of  the  pleura,  and  exacerbation  of  the  tuberculous  process.  It  has, 
however,  served  a  useful  purpose  in  so  far  as  it  has  called  attention  to  the 
possibility  of  gradual  reduction  of  deformity. 

Laminectomy:  The  operation  of  laminectomy,  or  trephining  the  spine, 
was  revived  by  Macewen,  and  has  been  performed  for  the  relief  of  paraplegia 
a  number  of  times  with  variable  success.  In  Pott's  disease  the  operation  is 
seldom  required,  and  should  be  reserved  until  all  conservative  measures  have 
been  exhausted,  and  complete  sensory  paralysis  has  resisted  all  mechanical 
methods  of  treatment,  unless  the  diagnosis  of  intraspinal  abscess,  tubercular 
masses,  or  a  spicule  of  bone  pressing  upon  the  cord  can  be  made.     If  any  of 


POTT'S  DISEASE  OF  THE  SPINE.  271 

these  forms  of  pressure  may  be  removed,  the  operation  will  be  of  great  benefit. 
The  time  when  the  operation  should  be  performed  wUl  depend  somewhat  upon 
the  pathology.  In  some  cases  the  pressure  of  an  abscess  upon  the  cord  is 
indicated  by  the  symptoms.  The  angular  deformity  occurs  early,  before  the 
signs  of  paralysis  are  manifested,  or  the  paralysis  after  its  institution  will  exhibit 
fluctuations  due  to  changes  in  the  tension  of  the  abscess  sac,  and  sometimes 
disappears  suddenly  from  the  bursting  of  the  abscess  and  the  relief  of  the  pressure. 
When,  however,  the  paralysis  results  from  the  pressure  of  a  cheesy  growth 
or  an  intraspinal  abscess,  it  sometimes  occurs  prior  to  the  advent  of  the  deformity, 
aad  fluctuations  do  not  occur,  the  disease  progressing  steadily  toward  the 
destruction  of  the  spinal  cord. 

The  operation  should  not  be  postponed  until  the  cord  has  become  completely 
disorganized,  so  that  if  the  loss  of  sensation  has  existed  for  some  time,  with 
the  occurrence  of  marked  rigidity,  the  operation  should  be  performed  earlier. 
Improvement  does  not  always  follow  immediately  after  the  performance  of 
this  operation,  and  recumbency  with  traction  should  be  continued  for  a  consider- 
able period. 

The  operation  of  laminectomy  consists  in  removing  the  vertebral  arches 
and  opening  the  spinal  canal.  An  incision  over  the  arches  to  one  side  of  the 
median  line  is  made,  the  muscles  and  periosteum  are  reflected,  and  the 
arches  are  divided  with  rongeur  forceps,  great  care  being  taken  not  to  injure 
the  dura.  The  cord  should  be  carefully  examined  by  means  of  a  probe  to 
see  that  all  pressure  is  removed.  If  the  cord  does  not  pulsate,  the  dura  may 
be  opened  and  the  examination  continued  in  a  search  for  masses  of  tuber- 
culous matter.  At  the  completion  of  the  operation  the  wound  is  packed 
with  sterile  gauze  and  the  patient  is  placed  upon  a  water-bed  or  in  the  prone 
position.  The  gap  which  is  left  in  the  spinal  column  by  the  operation  is  filled 
with  fibrous  tissue. 

The  mortality  of  this  operation  is  about  25  per  cent.,  and  this  fact  should 
be  carefully  considered,  since  these  patients  would  otherwise  live  for  years 
and  might  eventually  recover.  After  recovery  from  this  operation  an  ap- 
paratus should  be  worn  for  years,  since  the  spinal  column  has  been  distinctly 
weakened  by  the  removal  of  the  arches,  the  anterior  portion  having  been  pre- 
viously destroyed  by  disease. 


CHAPTER  II. 
NON-TUBERCULOUS  DISEASES  OF  THE  SPINE. 

Kyphosis. 

Kyphosis  is  a  deformity  characterized  by  a  posterior  curvature  of  the 
vertebral  column  in  part  or  in  its  entirety. 

Synonyms. — German,  Spitzbuckel;  Winkelf ormige ;  Knickung  der  Wir- 
belsaule;  Riickverbiegung  der  Wirbelsaule.  French,  Lordose.  English,  Spinal 
Excurvation  or  Posterior  Deformity. 

Adolescent  Kyphosis. — This  affection  is  of  very  frequent  occurrence, 
especially  among  young  girls.  It  is  more  often  found  to  be  hereditary  than 
is  lordosis,  and  it  is  not  so  common  as  scoliosis,  with  which  affection  it  is 
sometimes  associated.  Kyphosis  in  older  persons  is  much  more  rare  than 
in  adolescents. 

V  The  deformity  in  this  affection  may  be  extreme.  The  k3^hosis  can- 
not be  corrected  by  voluntary  effort,  and  after  a  time  it  becomes  permanent 
from  compensatory  osseous  changes.  It  is  most  commonly  met  with  in 
young  women  who  have  been  overtaxed  during  adolescence  in  the  field  or 
workshop.  The  curve  is  generally  in  the  dorsal  region,  but  it  may  involve 
the  entire  spinal  column  or  certain  sections  of  the  column.  The  usual  char- 
acteristic physical  signs  are  a  depression  of  the  anterior  bodies  of  the  verte- 
bras and  the  intervertebral  discs,  together  with  the  separation  of  the  trans- 
verse process  and  the  contraction  of  the  lamina.  Deformity  is  more  or  less 
severe,  according  to  the  degree  of  the  kyphosis,  the  vertebras  most  frequently 
affected  being  the  fifth,   sixth,   and   seventh  dorsal. 

The  diagnosis  of  kyphosis  is  frequently  very  difficult  to  determine.  The 
prognosis  is  usually  very  grave,  and  the  deformity  resulting  from  the  dor- 
sal prominence  becoming  permanent  is  apt  to  be  severe  and  unsightly. 

The  treatment  consists  in  strengthening  the  weakened  muscles,  and  in 
reducing  and  correcting  the  deformity  by  mechanical  means.  Some  bene- 
fit may  also  be  derived  from  forcible  correction  and  fixation.  A  useful  sup- 
port is  the  Morton  corset. 

Round    Shoulders. — When    the    shoulders    droop    forward    and    down- 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  273 

ward  there  occurs  what  is  familiarly  known  as  "round  shoulders."  This 
form  is  very  common  in  childhood  and  is  the  result  of  faulty  attitudes 
assumed  in  school.  It  is  also  increased  by  the  weight  of  shoulder-straps- 
The  head  droops  forward,  the  chest  is  narrowed,  the  lumbar  spine  is  arched 
forward,  and  the  chest  is  sometimes  flattened  and  sunken.  But  little  atten- 
tion has  hitherto  been  paid  to  this  very  frequent  deformity,  and  Lovett  has 
noted  that  in  all  of  the  principal  works  upon  orthopedics  up  to  the  present 
time  there  is  only  scant  mention  of  this  subject.  Recently  there  has  been 
some  note  made  of  the  faulty  attitudes  causing  round  shoulders,  with  some 
mention  of  shoulder-straps  and  braces  for  the  correction  of  the  deformity. 
Among  both  German  and  English  writers  in  dealing  with  this  subject  there 
has  been  some  discussion  as  to  what  the  normal  attitude  should  be,  and  to 
what  extent  certain  deviations  can  be  considered  as  abnormal.  The  diffi- 
culty experienced  in  classifying  the  degrees  of  deformity  from  faulty  attitude 
has  been  that  the  deviation  of  the  spine  alone  has  been  considered,  whereas 
the  relative  position  of  the  legs,  pelvis,  and  feet  should  also  be  considered. 
Any  accurate  adjustment  of  the  body  to  maintain  the  equilibrium  must 
necessarily  include  the  pelvis  and  lower  extremities.  In  studying  the  sub- 
ject of  round  shoulders  and  faulty  attitude  it  is  important  to  take  into  con- 
sideration just  what  the  normal  attitude  actually  is,  and  how  the  deviation 
from  the  normal  is  produced,  and  in  what  manner  this  deviation  can  best 
be  corrected. 

In  making  a  study  of  the  normal  attitudes  Lovett  has  collected  statistics 
showing  that,  in  measurements  taken  of  72  college  boys  and  100  college 
girls,  the  variations  among  the  girls  were  much  greater,  the  general  tendency 
being  to  carry  the  body  further  forward  and  to  hyperextend  the  knees,  the 
lumbar  curve  being  more  pronounced  in  the  boys.  Of  the  faulty  attitudes 
assumed  by  the  average  individual  there  are  four  types  of  curve  resulting: 
an  exaggerated  general  curve  from  the  mastoid  backward  to  the  fourth  lum- 
bar, a  backward  projection,  chiefly  in  the  mid-dorsal  region,  a  curve  in 
which  the  head  projects  forward  from  the  seventh  cervical  while  the  lower 
spine  remains  straight,  and  a  deformity  where  the  spinal  points  are  almost 
in  a  straight  line  and  the  back  nearly  flat.  This  classification  corresponds 
very  closely  with  that  of  Staffel,  in  his  "round  back,"  "round  hollow  back," 
"hollow  back,"  and  "flat  back." 

In  treating  round  shoulders  too  much  dependence  should  not  be  placed 
upon  the  use  of  apparatus,  but  the  English  military  brace  made  of  jean  has 

19 


274  ORTHOPEDIC  SURGERY. 

been  found  to  act  as  a  very  valuable  reminder.  In  my  experience  the  most 
useful  form  of  treatment  has  been  appropriate  gymnastic  exercises;  and  of 
these,  I  have  found  the  exercises  similar  to  the  "setting-up"  drill  of  the  cadet 
to  be  of  the  greatest  value.  Exercises  bringing  the  abdominal,  gluteal,  and 
hamstring  muscles  into  play  are  of  service,  and  the  raising  of  heavy  vireights 
has  been  found  of  benefit  in  exercising  the  muscles  which  maintain  the  body 
in  the  normal  standing  position.  All  the  exercises  should  aim  to  improve  the 
general  balance  of  the  body  as  well  as  to  correct  the  deviation  of  the  spinal 
column,  and  the  patient  should  also  take  a  certain  amount  of  rest  each  day 
to  enforce  the  benefit  from  the  gymnastic  exercises. 

Among  the  most  useful  exercises  for  the  correction  of  this  condition  is 
one  taken  with  the  patient  lying  upon  the  table  in  the  supine  position  with 
the  arms  at  the  sides  and  the  palms  turned  upward.  The  arms  are  brought 
forward  to  a  right  angle  with  the  chest,  the  hands  are  turned  over,  and  the 
arms  are  then  carried  upward  into  the  fully  extended  position,  and  are  then 
swept  outward  and  downward  to  the  first  position. 

Another  useful  exercise  is  taken  with  the  patient  in  the  supine  position, 
and  with  the  arms  at  the  sides,  a  one-pound  dumb-bell  is  grasped  in  each 
hand.  The  dumb-bells  are  then  brought  outward  and  upward  with  the  arms 
fully  extended,  the  palms  of  the  hands  facing  downward,  until  the  arms 
are  above  the  head,  and  from  this  position  they  are  carried  forward  in  the 
fully  extended  position  until  they  are  at  a  right  angle  with  the  body,  and  are 
then  slowly  brought  downward  to  the  first  position. 

In  taking  these  exercises  in  the  supine  position  it  is  best  to  have  the 
knees  bent  so  that  the  lumbar  region  rests  upon  the  table. 

Muscular  Kyphosis. — Kyphosis  may  result  from  muscular  weakness 
induced  by  faulty  attitudes  due  to  occupation.  This  form  is  met  in  tailors, 
cobblers,  carpenters,  and  among  laborers.  It  is  at  first  purely  muscular  from 
faulty  attitude  and  over-development  of  certain  muscles,  and  it  eventually 
becomes  permanent  from  changes  in  the  bone. 

The  severe  kyphosis  met  in  old  age  is  usually  the  result  of  tissue  meta- 
morphosis, absorption  occurring  in  the  intervertebral  discs,  the  curve  becom- 
ing permanent. 

The  kyphosis  which  results  from  spinal  meningitis  should  be  considered 
here.  Associated  with  the  deformity  of  the  lower  extremities, — spastic  con- 
tracture of  the  limbs  with  talipes  valgus  from  contraction  of  the  extensor 
longus  digitorum, — we  have  a  long  posterior  curve  in  the  spine  with  rigidity 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  275 

and  without  pain.  In  the  treatment  of  this  affection  the  writer  has  found 
it  best  to  discard  spinal  appliances  and  to  depend  upon  the  use  of  gymnastic 
exercises.  Apparatus  worn  upon  the  limbs  should  be  as  light  as  possible 
and  should  not  extend  any  higher  than  is  absolutely  necessary. 

Rachitic  Kyphosis. — The  kyphosis  met  in  rickets  is  most  marked  in 
the  lumbar  region  and  may  be  associated  with  lateral  curvature.  There 
are  always  associated  with  it  the  characteristic  changes  in  other  parts  of 
the  body,  the  open  fontanels,  rachitic  rosary,  enlarged  abdomen,  pendu- 
lous abdomen,  enlarged  epiphysis,  and  frequently  deformity  of  the  long 
bones.  The  deformity  in  rachitic  kyphosis  disappears  in  recumbency  and 
in  suspension. 

Chondrodystrophia. — In  fetal  rickets,  or  chondrodystrophia,  the  de- 
formity of  the  spine  is  similar  to  that  met  in  infantile  rickets,  but  the  early 
ossification  of  the  epiphysis  of  the  extremities  produces  an  appearance  which 
cannot  be  confounded  with  the  latter  disease.  Moreover,  it  has  usually 
associated  with  it  a  deformity  of  the  chest.  The  kyphosis  is  more  rigid  than 
in  infantile  rickets,  but  there  is  not  the  spasmodic  contraction  which  is  pres- 
ent in  Pott's  disease. 

Osteitis  and  Spondylitis  Deformans. — The  kyphosis  occurring  in 
these  affections  will  be  considered  in  its  proper  place. 

Scorbutic  Spondylitis. — The  occurrence  of  kyphosis  in  infantUe  scor- 
butus is  extremely  rare,  but  its  possibility  should  not  be  overlooked.  There 
are  usually  associated  with  it  other  joint  lesions  resembling  rheumatism,  the 
joints  being  enlarged,  red,  and  hot.  The  swollen  blue  gums  and  the  pur- 
puritic  ecchymoses  beneath  the  skin  and  mucous  membranes  should  render 
the  diagnosis  easy,  but  if  the  epiphysis  becomes  separated  by  ulceration  the 
affection  may  easily  be  mistaken  for  acute  epiphysitis  of  infancy  or  for  malig- 
nant disease.  The  treatment  should  consist  in  the  fixation  of  the  spine,  with 
improved  diet,  especially  the  use  of  peptone  preparations,  and  orange  juice. 

Typhoid  Spine. — The  secondary  infection  of  the  periosteum  and  bone 
which  follows  typhoid  fever  has  been  described  as  typhoid  spine  by  Gibney, 
although  the  disease  was  previously  noted  by  Maisonneuve  in  1835.  It  is 
characterized  by  a  stiffness,  localized  pain,  and  weakness  of  the  spine  occui'- 
ring  during  convalescence  from  typhoid  fever.  A  slight  kyphosis  usually 
occurs  and  the  pathologic  process  has  been  found  to  be  either  a  simple  peri- 
osteitis,  a  periosteitis  with  subperiosteal  abscess,  or  periosteitis  with  osteitis. 
The  pathologic  changes  in  the  spine  do  not  differ  from  those  which  are  met 


276 


ORTHOPEDIC  SURGERY. 


elsewhere  as  sequels  of  typhoid  fever.     The  spine  should  be  fixed  with  a  plas- 
ter cast,  and  recovery  is  the  rule. 

Syphilis  of  the  Spine. — This  rare  condition  of  the  spine  occurs  in  three 

forms — infantile  hereditary,  heredi- 
tary, and  acquired.  It  is  much  less 
common  than  Pott's  disease,  because, 
according  to  Fournier,  77  per  cent, 
of  these  children  are  still-born,  and 
it  is  a  well-known  fact  that  many  of 
them  die  during  the  first  years  of  in- 
fancy. The  affection  resembles  Pott's 
disease  in  the  kyphosis,  but  there  are 
manifestations  of  the  general  disease, 
there  is  an  absence  of  tubercular 
symptoms,  and  the  pain  resembles 
more  closely  that  in  sarcoma,  being 
of  a  local  character  rather  than  radi- 
ating to  the  anterior  region,  as  in 
Pott's  disease.  Muscular  rigidity  is 
marked. 

Traumatic  Spondylitis. — This 
is  quite  a  common  affection  among 
the  laboring  classes,  the  most  fre- 
quent lesion  being  a  rupture  of  the 
muscular  fibers  of  the  psoas  and 
Hiacus.  The  deformity  is  usually 
slight,  and  the  aft'ection  is  frequently 
mistaken  for  abscess  of  the  liver,  pan- 
creas, kidney,  and  other  viscera.  The 
history  of  an  injury  followed  soon  by 
a  lumbar  abscess  is  the  most  impor- 
tant diagnostic  sign  of  the  aft'ection. 
Traumatic  spondylitis  is  occasionally 
followed  by  caries  sicca,  either  involv- 
ing a  large  number  of  vertebras  and  giving  a  long  curved  k}^hosis,  or  invohing 
only  a  few  vertebras  and  producing  a  localized  kyphosis.  Injuries  to  the  liga- 
ments give  rise  to  the  symptoms  of  "railway  spine."     The  hypersensitive  con- 


FiG.  2  So. — Traumatic   Spondylitis   with  Psoas 
Abscess. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  277 

dition  of  the  skin  and  muscles,  excessive  spasm  upon  flexion,  and  atrophy  of 
the  erector  spinas  muscles  render  the  diagnosis  easy. 

It  is  more  difficult  to  make  a  correct  diagnosis  when  the  injury  occurs 
in  children  and  when  there  is  no  medico-legal  complication.  In  treating 
this  affection  the  abscess  should  be  evacuated  by  an  incision  above  Poupart's 
ligament  and  counter-drainage  should  be  established  in  the  lumbar  region. 
It  is  essential  that  the  spine  be  fixed  with  a  plaster  cast,  and  the  treatment 
should  be  conducted  in  the  same  manner  as  has  been  described  in  lumbar 
abscess  due  to  Pott's  disease. 

Infectious  Diseases  of  the  Spine. — Infectious  diseases  of  the  spine 
due  to  (i)  osteomyelitis,  (2)  actinomycosis,  and  (3)  gonorrhea  usually  pro- 
duce a  kyphosis. 

In  acute  osteomyelitis  pus  formation  occurs  early.  Large  sequestra 
form  and  the  course  is  rapid.  The  majority  of  these  cases  occur  during  adol- 
escence, from  overwork  and  trauma,  and  the  lumbar  spine  is  the  most  fre- 
quently affected.  It  is  frequently  mistaken  for  typhoid,  peritonitis,  pleur- 
isy, or  pneumonia.  Rigidity  with  spasm  and  local  pain  is  constant,  but 
deformity  is  present  in  less  than  10  per  cent,  of  the  cases.  Subsequently 
there  is  deep  fluctuation  with  venous  stasis  of  the  local  veins  and  edema.  In 
the  56  cases  analyzed  by  Grisel  the  body  was  affected  in  19,  the  posterior  arc 
in  21,  and  the  whole  vertebra  in  3.  Of  53  cases  carefully  reported,  30 
died  and  23  recovered.  Bacteriologic  examination  shows  Staphylococcus 
aureus  to  be  the  most  frequent  cause.  As  soon  as  deep  fluctuation  can  be 
detected,  the  abscess  should  be  incised  and  drained.  The  fistulas  are  not 
persistent. 

In  actinomycosis  the  separation  of  the  anterior  ligament  from  the 
bodies  of  the  vertebras  is  produced  by  the  formation  of  pus.  The  surface 
presents  a  worm-eaten  appearance  and  the  disease  is  of  such  extreme  rarity 
that  a  positive  diagnosis  cannot  be  made  from  the  physical  signs,  but  a 
microscopic  examination  of  the  pus  taken  from  the  sinuses  would  establish  a 
correct  diagnosis.  i 

The  spine  is  not  so  frequently  the  subject  of  gonorrheal  infection  as  many 
of  the  joints,  but  the  diagnosis  can  be  determined  from  the  history  of  sud- 
den onset  and  the  association  of  other  joint  lesions.  It  resembles  Pott's  dis- 
ease, but  is  more  painful  during  the  early  stage. 

Acromegaly. — The  kyphosis  in  acromegaly  is  sometimes  enormous, 
being  due,  as  pointed  out  by  Osborne,  to  an  absorption  of  the  intervertebral 


278 


ORTHOPEDIC  SURGERY. 


discs.     The  vertebras  are  sometimes  co-ossified  and  exostoses  mark  the  posi- 
tion of  the  intervertebral  discs. 

Hypertrophic  Pulmonary  Osteoarthropathy. — Kyphosis  is  sometimes 
present  in  hypertrophic  puhnonary  osteoarthropathy,  as  pointed  out  by  Marie. 
The  enlargement  of  the  articular  extremities  of  the  bones,  the  incurvation 
of  the  nails,  the  bulbous  swelling  of  the  terminal  phalanges,  and  the  enlarge- 
ment of  the  lower  jaw,  with  the  association  of  the  disease  of  the  lungs  and 
pleura,  would  render  the  diagnosis  clear. 

Malignant  Disease  of  the  Spine. — The  new-growths  met  in  the  spine 

are  sarcoma  and  carcinoma, 
both  of  which  are  commonly 
secondary.  Primary  carcinoma 
of  the  spine  may  be  considered 
a  pathologic  curiosity,  and 
primary  sarcoma  is  sufficiently 
rare  to  deserve  special  consider- 
ation. Sarcoma  is  met  in  three 
forms — lymphosarcoma,  spin- 
dle-celled sarcoma,  and  round- 
celled  sarcoma.  Charcot  con- 
firmed the  observ^ations  of  his 
predecessor,  Cazalis,  at  the 
Salpetriere  as  to  the  prevalence 
of  secondary  deposits  in  the 
lumbar  region  in  patients  who 
have  died  of  cancer  of  the 
breast,  both  in  men  and  women 
(Terrier),  giving  it  the  name  of 
paraplegia  dolorosa.  In  car- 
cinoma the  pain  is  lancinating,  anesthesia  is  absent,  and  hyperesthesia  is 
frequently  present.  Paralyses  of  the  bladder  and  rectum  are  late  or  absent, 
and  bedsores  are  apt  to  form.  The  writer  has  observed  several  cases  of 
secondary  sarcoma  and  has  reported  one  case  of  primary  sarcoma. 

Sarcoma  of  the  Spine. — In  this  condition  the  affected  region  of  the 
spine  projects  backward  in  two  round  masses  on  either  side  of  the  median 
line.  Subsequently  these  increase  in  size,  the  pain  increases  in  the  lumbar 
region,  and  peripheral  neural  pain  in  the  thighs  continues,  and   the   super- 


FiG.   281. — Primary  Sarcoma   of   Spine,  showikg  De- 
formity. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE 


279 


ficial  veins  of  the  abdomen  become  greatly  enlarged  and  the  abdomen  greatly 
distended.     The  emaciation  is  extreme.     Distinct  dullness  occurs  in  the  epi- 
gastric and  left  hypochondriac  regions,  and  the  circulation  in  the  superficial 
veins    of    the    abdomen    be- 
comes    reversed,     acting     as 
a     collateral     circulation     to 
the   obstructed   deep  circula- 
tion. 

Symptoms:  The  charac- 
teristic symptoms  are  pain, 
paraplegia,  grave  constitu- 
tional involvement,  rapid 
course,  and  metastasis.  In- 
continence of  urine  and  feces 
occurs  early  and  is  persistent. 
Amidon  has  reported  meta- 
stasis of  all  the  organs  and 
tissues;  the  liver,  kidneys, 
lungs,  and  muscles  of  the 
back  being  most  frequently 
affected.  In  my  case  the 
metastatic  growths  in  the 
postorbital  region  vi^ere  pecu- 
liar, but  there  were  probably 
growths  in  the  liver  and  in  all 
the  organs  of  the  abdomen. 
According  to  Edes,  the  pain 
in  sarcoma  of  the  spine  is  not 
nearly  so  severe  as  in  car- 
cinoma, whether  it  be  pri- 
mary or  secondary.  It  is  in- 
creased on  pressure,  on 
standing,  upon  sitting  up  quickly,  or  upon  turning  over  in  bed. 

Diagnosis:  The  diagnosis  may  be  made  from  the  severe  localized  pain, 
the  paraplegia  (paraplegia  dolorosa),  the  tenderness  over  the  spine,  the  de- 
formity being  rounded,  less  acute,  and  containing  no  bursa,  the  rapid  pro- 


FiG.  2S2. — Sarcoiia  of  Spine  showing  Venous  Stasis  and 
Metastatic  Growth  in  Okbit. 


280 


ORTHOPEDIC  SURGERY. 


gress  of  the  disease  and  the  seriousness  of  the  affection  from  the  very  earliest 
stages  to  the  fatal  termination. 

Differential  Diagnosis:  Primary  sarcoma  of  the  spine  may  be  con- 
founded with  a  number  of  affections,  including  the  following:  Pott's  dis- 
ease, caries  sicca,  rickets  of  the  spine,  neuromimesis,  sacro-Uiac  disease,  peri- 
nephritic  and  appendicial  ab- 
scesses, syphilis  of  the  spine, 
t}'phoid  spine,  senile  kyphosis, 
osteoarthritis,  Uiac  abscesses, 
severe  lateral  curvature,  hip- 
joint  disease,  lumbago,  sci- 
atica, spinal  irritation,  spinal 
meningitis  and  pachymening- 
itis, intraspinal  growths,  pos- 
terior spinal  sclerosis,  aneu- 
rysm, compression  myelitis, 
and  spina  bifida. 

I.  Pott's  Disease:  The 
most  frequent  disease  with 
which  sarcoma  of  the  spine 
is  confused  is  Pott's  disease 
of  the  spine.  The  two  most 
common  symptoms  of  sarcoma 
of  the  spine,  pain  and  para- 
plegia, are  present  also  in 
Pott's  disease,  but  the  per- 
sonal observation  of  the  writer 
leads  to  the  belief  that  there 
is  a  difference  in  both  these 
symptoms.  The  pain  in  sar- 
coma is  located  in  the  region  of  the  deformity  or  may  be  radiated  to  the  thighs. 
In  Pott's  disease  there  is  seldom  pain  in  the  lumbar  region  and  peripheral  pain 
is  always  most  marked.  Paraplegia  is  present  in  sarcoma  very  early,  is 
associated  with  incontinence  of  urine  and  feces,  and  is  persistent.  In  Pott's 
disease  paraplegia  comes  on  gradually.  When  the  paraplegia  is  advanced  and 
due  to  compression  myelitis,  the  S3'mptoms  are  much  the  same  in  both.  Muscu- 
lar spasm,  due  to  the  irritation  of  the  psoas  muscles  and  the  erector  spinse  mus- 


-Aggravated  Type  of  Lateral  Curvature  Re- 
sembling Sarcoma  oe  Spine. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  .  281 

cles,  occurs  in  both.  The  attitude  is  much  the  same  in  both,  the  body  being 
flexed  and  the  lower  extremities  contracted.  The  local  pain  and  tenderness 
are  present  in  sarcoma,  but  are  absent,  or  very  seldom  present,  in  Pott's  disease. 
The  deformity  in  sarcoma  is  rounded,  less  acute,  and  the  projection  of  the 
vertebras  does  not  have  a  bursa  upon  it,  as  pointed  out  by  Tubby.  In  Pott's 
disease  the  deformity  is  medium,  angular,  and  permanent  except  in  the  rare 
instances  in  which  there  is  lateral  deviation  of  the  spinous  processes  from 
unilateral  spasm.  In  sarcoma  of  the  spine  suppuration  does  not  occur, 
whereas  in  Pott's  disease  abscesses  occur  frequently.  The  general  system 
suffers  quickly  in  sarcoma,  emaciation,  edema,  and  cachexia  being  constant 
symptoms;  whereas  in  Pott's  disease  the  emaciation  is  a  late  symptom  from 
profuse  suppuration,  cachexia  if  present  is  a  very  late  symptom,  and  edema 
if  it  occurs  is  due  to  anemia  or  renal  disease,  and  not  to  obstruction. 
The  following  table  will  render  the  diagnosis  clearer: 

Pott's  Disease.  Primary  Sarcoma  of  Spine. 

1.  Antecedents, Tuberculous.  Malignant. 

2.  Duration, Slow.  Rapid. 

3.  Malaise, General  malaise  early.    Cachexia     Cachexia  early. 

late  from  kidneys. 

4.  Pain, Peripheral.      Absence    of     local     Local  tenderness  present. 

tenderness. 

5.  Deformity, Present  and  angular.  Absent    or    rounded,    without 

bursa. 

6.  Abscesses, Present.  Absent. 

7.  Paraplegia, Late  and  Partial.  Early  and  complete. 

8.  Emaciation  and  ane- 

mia,   Occurs  late.  Occurs  early. 

9.  Cachexia, Absent  or  late.  Early  and  persistent. 

10.  Edema,  Rare.     Renal.  Common.     Obstructive. 

11.  Temperature,    Hectic.  Apyretic. 

12.  Location,   Most  frequent  in  dorsal  region.  Most  frequent  in  lumbar  region. 

13.  Infection, General    to    nervous  system   or  Metastasis  to  all  organs,  espe- 

lungs.  dally  the  hver. 

2.  Caries  Sicca:  The  flexion  of  the  spine,  the  disability,  the  pain,  in 
caries  sicca  associated  with  a  history  of  traumatism,  would  in  some  cases 
lead  to  an  incorrect  diagnosis,  but  the  long  curve  which  is  always  present, 
its  angularity,  the  absence  of  local  tenderness  and  peripheral  pain,  and  in  some 
cases  the  association  of  osteoarthritis  in  other  joints  (rhizomelic  spondylosis) 
would  lead  to  a  correct  diagnosis. 

3.  Rickets  of  the  Spine:    The  deformity  in  the  lumbar  region  together 


282 


ORTHOPEDIC  SURGERY. 


with  the  pseudoparaplegia  (of  Perrott)  might  be  confusing,  since  sarcoma 
occurs  in  children  as  well  as  in  adults.  The  presence  of  rachitic  conditions 
in  other  parts  of  the  body,  the  open  fontanels,  the  enlarged  epiphyses,  the 
rachitic  rosary,  and  the  protruding  abdomen  would  quickly  decide  the  ques- 
tion. 

4.  Neuromimesis:  A  careful  clinician  should  not  be  misled  by  the 
varied  manifestations  of  hysteria.     A  correct  diagnosis  may  usually  be  made 

by  observing  the  presence 
of  an  inherited  or  acquired 
neurotic  diathesis,  the 
simultaneous  appearance 
of  pain  and  deformity,  the 
correspondence  of  the  hy- 
peresthetic  and  paresthetic 
areas  to  the  distribution  of 
the  nerve-branches,  instead 
of  the  unmistakable  signs 
of  organic  disease  met  in 
sarcoma. 

5.  Sacro-iliac  Disease: 
Sacro-Uiac  disease  resem- 
bles sarcoma  in  the  deform- 
ity, in  the  local  tenderness, 
and  in  the  disability,  but  the 
location  of  the  deformity 
and  the  sensitiveness  are 
different.  There  is  no  psoas 
irritation  and  the  body  in 
the  characteristic  attitude 
('•position  hanche"  of  Hattute)  is  inclined  to  the  opposite  side  and  not  forward. 
Moreover,  there  is  frequently  a  history  of  tuberculosis,  inherited  or  acquired, 
and  an  absence  of  cachexia,  except  in  the  very  advanced  stages  of  the  disease. 
Abscesses  are  frequent  in  sacro-iliac  disease. 

6.  Perinephritic  and  Appendicial  Abscesses:  Both  these  diseases  have 
one  symptom  in  common  with  sarcoma,  psoas  ii-ritation  and  contraction  of 
one  or  both  thighs.  In  the  absence  of  abscess  a  diagnosis  may  be  made  by 
careful  differentiation  of  the  symptoms  of  these    two    affections  from   those 


Fig.  284. — Traumatic  Spine.     Caries  Sicca. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  283 

which  are  met  in  sarcoma.  In  the  absence  of  urinary  symptoms  the  pres- 
ence of  pain,  edema,  and  tenderness  upon  pressure  over  the  region  of  the 
kidney,  with  nausea  and  vomiting,  and  the  absence  of  the  cardinal  symp- 
toms of  sarcoma  will  differentiate  perinephritic  disease.  The  rapid  onset 
of  epigastric  or  umbilical  pain  with  vomiting,  the  presence  of  acute  localized 
tenderness  with  unilateral  rigidity  of  the  abdominal  walls,  intestinal  disturb- 
ances' with  rapid  pulse  and  moderate  temperature,  will  serve  to  distinguish 
appendicitis  from  primary  sarcoma. 

7.  Syphilis  of  the  Spine:  This  rare  condition  of  the  spine,  whether  pri- 
mary or  secondary,  resembles  sarcoma  in  the  deformity  and  in  the  local  ten- 
derness, but  it  is  more  common  in  adults,  and  affects  the  upper  part  of  the 
column  more  frequently  than  the  lower;  moreover,  the  history  of  acquired 
or  congenital  specific  disease,  the  presence  of  lesions  in  other  parts  of  the 
body,  and  the  long  continuance  of  the  affection,  together  with  the  absence 
of  the  characteristic  symptoms  of  malignant  disease,  would  lead  to  a  correct 
opinion.     This  condition  has  been  observed  by  the  writer  in  an  infant. 

8.  Typhoid  Spine:  In  typical  cases  the  resemblance  of  the  spondylitis 
which  occurs  after  typhoid  fever  to  sarcoma  is  apparent  in  the  tenderness 
upon  pressure,  the  severe  pain,  and  the  increase  in  temperature;  but  the  his- 
tory of  the  case,  the  absence  of  deformity,  and  the  disappearance  of  the  affec- 
tion under  appropriate  treatment  would  serve  to  distinguish  it  from  sarcoma. 

9.  Senile  Kyphosis:  The  severe  kyphosis  which  sometimes  accompanies 
old  age  resembles  sarcoma  in  the  deformity,  but  the  curve  is  more  frequently 
in  the  dorsal  region  and  there  is  an  absence  of  the  acute  symptoms,  the 
cachexia,  and  the  more  serious  symptoms  which  are  characteristic  of  the 
latter  disease. 

10.  Osteoarthritis:  The  occurrence  of  osteoarthritis  in  the  spine  shows 
a  resemblance  to  sarcoma  in  the  rigidity,  the  contraction  of  the  lower  limbs, 
and  the  obliteration  of  the  normal  lordosis,  but  the  history  of  traumatism,  the 
association  of  the  disease  with  lesions  of  the  other  joints  (hip  and  shoulder), 
the  absence  of  a  marked  k3^hosis  in  the  lumbar  region,  and  the  absence  of 
the  grave  symptoms  of  malignant  disease  will  be  sufficient  to  prevent  con- 
fusion. 

11.  Iliac  Abscesses:  The  large  coUections  of  pus  in  the  iliac  fossa 
from  tuberculosis  of  the  spine  and  other  causes  sometimes  resemble  malig- 
nant disease  of  the  spine,  particularly  when  they  occur  in  adults.  The 
history  of  traumatism,  the  unilateral  character  of  the  affection,  the  presence 


284  ORTHOPEDIC  SURGERY. 

of  fluctuation  with  a  mass  in  the  iliac  region,  and  the  absence  of  the  cardinal 
symptoms  of  maHgnant  disease  will  distinguish  this  lesion. 

12.  Severe  Lateral  Curvature:  In  severe  primary  lumbar  lateral  cur- 
vature where  deformity  and  pain  are  prominent  symptoms  the  resemblance 
to  sarcoma  is  sometimes  very  striking.  This  is  particularly  true  in  adults, 
as  in  a  case  under  the  -m-iter's  observation  in  a  single  woman  aged  fifty-six 
years,  who  had  fallen  eight  years  before,  and  who  presented  a  great  deform- 
ity of  the  lumbar  region,  with  excruciating  pain  in  this  region,  radiating  to 
the  thighs.  The  history  of  the  attack,  the  long  period  of  the  disease,  the  pres- 
ence of  compensatory  curves,  the  absence  of  cachexia,  and  the  general  health 
of  the  indi'V'idual  would  lead  to  a  correct  diagnosis.  iMoreover,  the  deformity 
is  always  unilateral. 

13.  Hip- Joint  Disease:  The  resemblance  between  hip-joint  disease  and 
the  lesions  of  the  lumbar  region,  whether  tubercular  or  otherwise,  is  ofttimes 
very  striking.  Psoas  irritation  is  present  in  hip-joint  disease  and  also  in  sar- 
coma, but  the  history  of  a  tuberculous  diathesis,  of  traumatism,  the  location 
of  the  pain  in  the  knee,  the  fixation  of  the  joint,  ■with  the  characteristic  de- 
formities of  the  dift'erent  stages,  the  changes  in  the  gluteofemoral  fold,  with 
the  swelling,  induration  and  pain,  particularly  in  the  trochanter,  with  the 
formation  of  abscesses,  would  render  the  diagnosis  distinct  from  that  of 
malignant  disease. 

14.  Lumbago:  The  resemblance  between  severe  lumbago  and  malig- 
nant disease  of  the  spine  is  very  characteristic,  and  a  severe  lumbago  resist- 
ing treatment  and  continuing  for  a  long  period  should  excite  suspicion  of 
malignant  disease.  The  evanescent  character  of  the  aft'ection  and  the  rapid 
amelioration  under  proper  treatment,  together  with  the  absence  of  symp- 
toms characterizing  malignant  disease,  should  render  the  diagnosis  of  ordinary 
lumbago  simple. 

15.  Sciatica:  The  pains  in  the  sciatic  region  occurring  in  sarcoma  of 
the  spine  resemble  sciatica  so  closely  that  the  occurrence  of  double  sciatica 
without  other  history,  especially  of  diabetes,  should  lead  to  a  very  careful 
examination  for  sarcoma  of  the  spine.  The  pain  is  more  severe  in  cases  of 
carcinoma  of  the  spine.  Painful  paraplegia  from  sarcoma  of  the  spine  has 
been  reported  by  Kemper. 

16.  Spinal  Irritation:  The  sjTnptoms  in  spinal  irritation  resemble  those 
met  in  sarcoma,  but  in  the  former  affection  the  spinal  tenderness  is  more  ex- 
quisite and  general  and  the  pains  are  non-neural,  evanescent,  and  fugitive. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  285 

Spinal  irritation  is  more  frequent  in  females  and  the  history  of  the  patient 
would  assist  in  arriving  at  a  correct  diagnosis. 

17.  Spinal  Meningitis  and  Pachymeningitis:  The  symptoms  in  these 
affections  are  characteristic  of  themselves,  but  as  there  is  some  similarity  to 
those  of  sarcoma,  it  is  necessary  to  call  attention  to  the  possibility  of  confus- 
ing the  two.  These  diseases  and  sarcoma  are  equally  rare,  but  the  former 
are  characterized  by  non-neural  pains  and  various  spasmodic  conditions, 
which  are  pathognomonic. 

18.  Intraspinal  Growths:  Intraspinal  growths  of  a  benign  nature  pro- 
duce symptoms  resembling  sarcoma.  In  fact,  when  the  secondary  lesions 
of  sarcoma  invade  the  spinal  canal  a  differential  diagnosis  would  be  impos- 
sible. Peripheral  pain  without  paraplegia  and  the  early  appearance  of  para- 
plegic symptoms  with  a  marked  deformity,  localized  tenderness,  and  char- 
acteristic signs  of  a  serious  malignant  type  of  disease  would  suggest  the 
possibility  of  an  intraspinal  growth.  The  vasomotor  disturbances,  in  the 
experience  of  the  writer,  are  quite  characteristic  of  a  benign  growth  in  the 
spinal  canal. 

19.  Posterior  Spinal  Sclerosis:  The  classic  symptoms  of  locomotor 
ataxia  are  so  characteristic  that  it  could  not  readily  be  confused  with  malig- 
nant vertebral  diseases.  Moreover,  the  presence  of  ataxia,  the  diminution 
of  reflexes,  impaired  sensations,  the  absence  of  all  pain,  the  pupillary 
changes  (Argyll-Robertson  pupil),  and  incoordination  would  serve  to  dis- 
tinguish locomotor  ataxia  from  malignant  spinal  disease. 

20.  Aneurysm:  Aneurysm  of  the  abdominal  aorta  eroding  the  verte- 
bral bodies  produces  symptoms  which  resemble  sarcoma,  especially  in  the 
length  of  the  curve  and  the  localized  pain.  This  affection  occurs  late  in  life, 
and  in  addition  to  these  symptoms  there  are  added  the  characteristic  symp- 
toms of  aneurysm  which  would  render  the  diagnosis  clear. 

21.  Compression  Myelitis:  This  disease  resembles  sarcoma  of  the  spine 
in  the  lumbar  region  very  closely,  especially  in  the  early  supervention  of  par- 
alysis with  vesical  and  rectal  disturbances;  but  the  absence  of  acute  pain 
and  the  presence  of  the  pressure  symptoms,  together  with  the  history  of  the 
patient,  would  lead  to  an  early  recognition  of  this  affection. 

22.  Spina  Bifida:  The  resemblance  between  lumbosacral  spina  bifida 
and  sarcoma  in  this  region  has  been  pointed  out,  but  the  fluctuation  and 
translucency,  and  especially  the  arborescent  zone  of  vascularization,  will  aid 
in  differentiation.     Moreover,  spina  bifida  is  congenital. 


286  ORTHOPEDIC  SURGERY. 

Prognosis:  In  the  present  state  of  medical  knowledge  there  is  but  one, 
a  fatal  prognosis,   in  these  cases. 

Lordosis. 

Lordosis  is  a  deformity  characterized  by  an  anterior  curvature  of  a 
part  or  the  whole  of  the  vertebral  column. 

Synonyms. — German,  Vorverbiegung  der  Wirbelsaule;  Lordotische  sko- 
liose.    French,  Lordose.     English,  Spinal  Incurvation  or  x^nterior  Deformity. 

It  may  occur  in  any  part  of  the  spine,  but  is  most  common  in  the  lum- 
bar region.  It  is  characteristic  of  some  races,  as  the  Terra  del  Fuegans  and 
Cubans.  It  is  present  in  professional  contortionists,  and  in  those  whose 
occupations  compel  them  to  carry  heavy  weights  upon  their  heads,  and  in 
tailors  from  acquired  contraction  of  the  iliopsoas  muscle.  It  may  be  clas- 
sified under  three  heads — compensatory,  paralytic,  and  pathologic. 

Compensatory. — It  occurs  as  a  compensatory  symptom  in  kyphosis 
of  the  dorsal  region  from  an  effort  to  establish  the  equilibrium  of  the  spine, 
in  pregnancy  either  as  a  temporary  or  permanent  condition,  from  the  ab- 
dominal enlargement  in  rickets,  or  from  tumors.  It  is  seen  in  congenital 
dislocation  of  the  hip  from  the  posterior  position  of  the  head  of  the  bone. 
It  is  also  a  symptom  in  contraction  of  the  spinal  muscles. 

Paralytic. — The  paralytic  form  of  lordosis  is  present  in  progressive  mus- 
cular atrophy,  in  pseudo-muscular  palsy,  and  in  paralysis  of  the  abdominal 
muscles  of  the  pelvic  extensors. 

Pathologic. — The  pathologic  form  is  encountered  in  hip  disease,  either 
single  or  double,  from  contraction  or  ankylosis.  It  is  present  in  contraction 
of  the  hip  from  infantile  palsy,  and  may  be  observed  in  the  early  stage  of 
lumbar  Pott's  disease.  It  is  a  marked  symptom  in  spondylolisthesis,  which 
affection  constitutes  so  important  a  deformity  that  it  will  be  considered  sepa- 
rately. 

The  different  varieties  of  lordosis  require  appropriate  treatment  accord- 
ing to  the  severity  of  the  deformity,  the  treatment  consisting  in  the  use  of 
electricity,  massage,  the  application  of  spinal  appliances,  and  the  correction 
of  the  deformity  which  has  produced  the  compensatory  change.  The  spinal 
appliances  consist  of  a  firm  pelvic  band  with  elastic,  tempered,  spinal  up- 
rights, to  which  are  attached  axillary  bands,  and  an  abdominal  apron,  or  an 
abdominal  and  thoracic  band. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  287 

Spondylolisthesis. 

The  spondylolisthetic  pelvis  was  first  described  by  Rokitanski,  who  re- 
ported two  cases  in  1839,  and  the  name  spondylolisthetic  (from  fj-m8oh>q^ 
"a  vertebra,"  and  cxinOrjaiq^  "a  slipping  down  or  out")  was  given  it  by 
Kilian  in  1853,  who  gave  the  first  accurate  description.  The  knowledge  of 
the  condition  is,  however,  mainly  due  to  Neugebauer,  who  collected  over 
ninety  cases  and  specimens,  and  its  etiology  has  been  greatly  cleared  up 
by  the  discoveries  of  Lane.  The  condition  is  more  common  in  females, 
Schlesier,  up  to  1892,  having  collected  fifty-three  cases  in  skeletons,  only  three 
of  which  were  male.  This  may  be  due  largely  to  the  sexual  differences  in 
the  inclination  of  the  pelvis.     The  condition  is  uncommon. 

Spondylolisthesis  may  occur  in  other  vertebras,  but  is  most  common 
in  the  lumbosacral  articulation.  The  name  is  descriptive  of  the  condition, 
which  is  produced  mainly  by  two  factors:  (i)  a  malformation,  and  (2)  strain 
or  violence.  Because  of  its  embryonal  origin  being  from  different  centers 
it  occasionally  occurs  that  the  bony  development  of  the  last  lumbar  vertebra 
is  imperfect  from  non-union  of  its  component  parts.  In  other  words,  between 
the  upper  and  lower  articular  processes  the  bony  ring  is  sometimes  cartilagin- 
ous or  composed  of  fibrous  tissue.  While  spondylolisthesis  is  rare,  this  de- 
fect in  ossification  (called  spondylysis  articularis)  is  common,  although  by 
itself  being  insufficient  to  cause  the  deformity.  In  considering  the  second 
factor,  strain  or  violence,  we  find  that  if  a  patient  with  this  malformation  has 
had  to  do  very  heavy  labor,  or  is  exceedingly  obese,  or  if  by  violence  the  spinal 
column  is  suddenly  driven  down,  a  fracture  may  occur  at  the  line  of  imper- 
fect union  with  a  dislocation  forward  of  the  vertebral  body  and  upper  arti- 
cular processes.  This  deformity  will  arise  gradually  if  from  strain,  and  sud- 
denly if  from  violence.  In  some  cases  the  patient  gives  a  history  of  a  long 
preceding  illness  during  the  development  of  the  deformity,  but  this  may  be 
coincidental.  While  it  is  claimed  that  spondylolisthesis  may  arise  without 
any  defect  in  ossification — one  or  two  cases  having  been  reported — there 
would  necessarily  be  either  a  dislocation  anteriorly  of  the  last  lumbar  vertebra 
with  the  sacral  articular  processes  after  fracture  of  these  processes,  or  frac- 
ture of  the  articulating  portion  of  a  normal  last  lumbar  vertebra;  both  oc- 
currences being  theoretic. 

Secondary  Changes. — When  the  deformity  has  occurred  the  mechan- 
ical conditions  of  the  bones  are  altered  and,  according  to  Wolff's  law,  the 
structure  is  greatly  changed.     The  changes  occur  as  follow:    (i)  The  canal 


288  ORTHOPEDIC  SURGERY. 

of  the  last  lumbar  vertebra  is  enlarged  from  before  backward.  (2)  The  body 
of  the  vertebra  is  not  supported  in  front  in  its  new  position  and  sinks  down, 
its  anterior  portion  forming  an  angle,  opening  downward,  with  its  posterior 
portion.  (3)  Between  the  weight  of  the  bony  column  above  and  the  pres- 
sure of  the  sacrum  below,  the  body  is  compressed  behind  and  becomes 
bluntly  wedge-shaped,  the  base  of  the  wedge  being  anterior.  (4)  The  slip- 
ping forward  of  the  last  lumbar  vertebra  throws  an  unusual  strain  upon  the 
intervertebral  substance  between  it  and  the  sacrum,  and  the  result  of  this 
strain  is  the  growth  of  bony  substance  in  the  intervertebral  tissue,  and  in  the 
angle  between  the  displaced  lumbar  vertebra  and  the  first  sacral  vertebra. 
This  last  change  is  really  conservative  in  character,  as  it  prevents  further 
dislocation.  (5)  Because  of  the  different  disposition  of  the  body-weight  there 
is  also  a  backward  dislocation  of  the  sacrum  and  a  flattening  of  the  sacral 
canal. 

There  are  four  stages  of  the  deformity,  according  to  the  degree:  (i) 
When  it  projects,  (2)  when  it  hangs  over  toward  the  pelvic  brim,  (3)  when 
it  has  sunk  into  the  pelvic  brim,  and  (4)  when  it  has  sunk  into  the  pelvic 
cavity. 

The  defect  in  ossification  may  be  present  only  on  one  side,  in  which 
case  the  last  lumbar  vertebra  will  slip  forward  on  this  side  the  more  easily, 
producing  an  asymmetric  deformity.  The  disease  is,  however,  so  rare  that 
it  is  unnecessary  to  describe  the  various  modifications  in  particular  speci- 
mens due  to  the  degree  in  the  advance  of  the  morbid  changes. 

On  account  of  the  pelvic  changes  in  spondylolisthesis  and  their  diag- 
nosis there  are  three  important  points  to  be  considered:  (i)  There  will  usu- 
ally be  a  history  of  some  violence  or  strain  resulting  in  a  protracted  illness 
severe  enough  to  render  confinement  to  bed  necessary,  and  attended  with 
pain  in  the  lower  part  of  the  back.  This  injury  usually  occurs  during  the 
age  of  the  development  of  the  pelvis — from  the  fifteenth  to  the  eighteenth 
year.  (2)  There  is  a  marked  bodily  deformity,  there  being  a  shortening  of 
the  body  in  the  lumbar  region.  In  severe  cases  the  ribs  are  sunk  into  the 
false  pelvis,  and  in  less  severe  cases  approximate  the  iliac  crests.  This 
renders  conspicuous  the  great  breadth  between  the  wings  of  the  ilia,  espe- 
cially viewed  posteriorly.  (3)  Lordosis  is  markedly  present  and  the  ante- 
rior edges  of  the  bodies  of  the  lumbar  vertebras  are  widely  separated  while 
the  posterior  portions,  the  articular  processes  and  neural  arches,  are  pressed 
together,  which    pressure  may  cause  the  development  of   osteomata,  ossifica- 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  289 

tion  of  the  ligaments,  and  possibly  synostosis.  The  back  of  the  sacrum  is 
plainly  felt,  and  the  posterior  superior  iliac  spines  are  further  apart  than 
ordinarily  because  of  the  backward  pressure  of  the  sacrum  and  the  separa- 
tion of  the  ilia.  The  genitals  look  further  forward  than  under  normal  con- 
ditions because  of  the  lessening  of  the  inclination  of  the  pelvis.  The  abdo- 
men is  creased  above  the  symphysis,  the  flanks  are  fuller,  and  the  buttocks 
assume  a  very  peculiar  heart-shape,  tapering  together  and  ending  in  a 
point  below,  and  they  are  also  flattened.  The  gait  is  peculiar,  the  patient 
walking  with  short  steps,  and  the  feet  slightly  inverted,  so  that  the  foot- 
marks are  deficient  in  breadth.  The  legs  turn  inward,  and  as  the  patient 
walks  are  placed  one  in  front  of  the  other. 

The  promontory  in  the  spondylolisthetic  pelvis  is  not  a  sharp  angle  be- 
cause of  the  new  osseous  growth,  but  upon  digital  examination  the  al«  of  the 
sacrum  are  distinctly  felt,  and  the  abdominal  aorta  with  its  bifurcations  may 
also  be  felt,  and  sometimes  the  lower  borders  of  the  kidneys  may  be  detected 
upon  palpation. 

The  presence  of  spondylolisthesis  seriously  interferes  with  delivery  in 
labor,  since  even  if  the  measurements  be  only  slightly  lessened  malpresen- 
tations  are  not  uncommon,  and  fistulas  and  lacerations  not  infrequent.  A 
large  proportion  die  in  labor. 

Deformities  of  the  Thorax. 
Deformities  of  the  chest  are  either  congenital  or  acquired,  and  are  of  three 
principal  types — funnel  chest,  flat  chest,  and  pigeon  breast.     The  congenital 
are  chiefly  due  to  fissure  and  defects,  and  the  acquired  generally  result  from 
pathologic  conditions,  notably  from  rickets. 

Congenital. 

Congenital  deformities  of  the  chest  are  very  rare  and  are  usually  found 
in  monstrosities  or  in  persons  suffering  from  a  complication  of  deformities. 
The  deformities  arising  from  congenital  causes  are  of  different  varieties.  The 
sternum  may  be  entirely  absent  or  only  partially  so,  and  frequently  it  is  fissured 
about  the  median  line,  the  ribs  being  attached  to  either  side  of  the  fissure, 
which  is  sometimes  subdivided  transversely  by  bands  of  tissue,  and  there  is 
often  a  separation  of  the  sternum,  triangular  in  shape,  with  the  base  upward, 
during  respiration.  There  may  exist  a  hernia  of  the  lung  through  the  fissure. 
In  the  partial  or  total  absence  of  the  sternum  it  may  be  replaced  by  a  fibrous 

20 


290 


ORTHOPEDIC  SURGERY. 


Fig.  285. — Funnel  Chest.    Front  View  (Richards). 


structure  to  which  the  ribs  are  sometimes  attached,  while  at  other  times  they 
may  be  free.  There  may  be  only  a  partial  development  of  the  sternum,  in 
which  case  the  ribs  on  the  affected  side  are  free  and  the  interA-ening  space  is 

filled  in  by  membrane  which 
bulges  during  expiration  and 
retracts  during  inspiration. 
Pulsation  of  the  heart  and 
aorta  may  be  noted  through 
this  membrane.  There  may 
also  be  perforation  of  a  sec- 
tion of  the  sternum. 

There  may  exist  an  ab- 
sence of  one  or  more  verte- 
bras, which  is  usually  asso- 
ciated with  rachischisis,  but 
it  may  be  present  with  no 
other  symptom  than  a  notice- 
able shortening  of  the  spine, 
and  is  usually  associated  with  some  defective  formation  of  the  corresponding 
muscles.  The  pectoral  muscles — pectoralis  major,  pectoralis  minor,  inter- 
costals,  and  serratus  major — 
may  be  absent  or  defec- 
tive, which  will  cause  de- 
formity but  appears  to  give 
rise  to  no  direct  symptoms, 
and  is  probably  the  result 
of  some  mechanical  inter- 
ference. This  congenitalde- 
fect  of  the  muscles  is  usu- 
ally unilateral  in  character, 
whereas  the  acquired  form  is, 
aa  a  rule,  bilateral.  The 
defect  in  the  muscles  is  fre- 
quently discovered  only  by 
accident,  since  it  causes  the 

patient  little  or  no  inconvenience,  the  principal  symptom  being  that  of  fatigue. 
Deformity  may  sometimes  be  produced  by  absence  of  the  clavicle,   as 


Fig.  286. — Funnel  Chest.     Side  View  (Richards). 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  291 

referred  to  in  the  chapter  upon  Non-tuberculous  Diseases  of  the  Shoulder. 
In  some  instances  it  may  result  from  the  absence  of  one  or  more  ribs,  the  in- 
tervening space  being  filled  with  membrane;  or  there  may  be  an  increase  over 
the  normal  number  of  ribs.  As  the  increase  is  usually  an  additional  cervical 
rib  or  pair  of  ribs,  the  chest  is  increased  in  length. 

Funnel  Chest. — Synonyms:  pectus  excavatum,  Trichterbnist.  This  variety 
of  deformity  of  the  chest  is  almost  without  exception  congenital,  but  in  very 
rare  instances  it  may  be  associated  with  Pott's  disease  or  with  rickets.  It 
is  sometimes  a  hereditary  condition,  and  has  been  described  particularly  by 
Ebstein  and  Klemperer.  It  is  due,  according  to  Zuckerkandl  and  Ribbert, 
to  the  pressure  of  the  inferior  maxillary  bone  upon  the  inferior  segment  of  the 
sternum  during  fetal  life.  Ebstein  attributes  the  deformity  to  an  arrest  of  devel- 
opment of  the  sternum.  It  might  be  due  to  dystrophy  of  the  muscles  of  the 
back  and  scapulas,  which  was  the  cause  in  the  case  illustrated. 

It  is  characterized  by  a  depression  of  the  entire  sternum,  the  costal  cartilages 
forming  the  lateral  borders  of  the  infundibulum,  while  the  abdominal  wall 
forms  the  inferior  border.  The  extensive  depression  of  the  sternum  has  the 
effect  of  increasing  the  transverse  diameter  of  the  chest,  but  otherwise  has  no 
influence  upon  the  direction  of  the  spinal  column. 

Acquired. 

The  acquired  varieties  of  deformity  of  the  thorax  are  generally  due  to 
rickets,  but  may  result  from  obstruction  to  respiration  or  from  mechanical 
conditions,   or  it  may  result  from  avocation. 

Flat  Chest. — This  deformity  is  characteristic  of  certain  professions,  such 
as  shoemakers,  lace  and  embroidery  makers,  etc.,  and  consists  of  a  sinking 
in  of  one  side  of  the  chest  at  the  level  of  the  xiphoid  process.  It  is  frequently 
associated  with  round  shoulders,  the  flat  appearance  of  the  chest  being 
partially  due  to  the  displacement  forward  of  the  shoulders  and  scapulas.  Where 
not  the  result  of  avocation,  it  is  simply  an  exaggeration  of  the  normal  flat  chest 
through  round  shoulders  or  kyphosis. 

Pigeon  Breast. — Synon3Tns:  Huhnerhrust,  Kahnbrust,  pectus  carinatum, 
poitrine  en  carene,  poitrine  de  pigecm.  This  deformity  is  characterized  by 
the  projection  of  the  sternum  and  cartilages  in  the  form  of  a  keel,  or  similar 
in  shape  to  the  breast  of  a  bird,  the  lateral  compression  being  most  pronounced 
at  the  junction  of  the  ribs  and  cartilages.  The  transverse  diameter  is  enlarged 
and  the  lateral  diameter  is  diminished.     There  may  be  a  second  depression 


292  ORTHOPEDIC  SURGERY. 

occurring  in  the  mid-axillary  region,  and  by  reason  of  the  strain  upon  the 
diaphragm  there  sometimes  occurs  a  third  depression,  oblique  in  character,  at 
about  the  level  of  the  ensiform  cartilage.  The  capacity  of  the  chest  and 
respiratory  organs  is  greatly  diminished,  especially  when  the  deformity  is  asso- 
ciated with  Pott's  disease,  and  there  is  pronounced  dyspnea,  with  palpitation 
of  the  heart.  This  symptom  is  also  characteristic  of  the  deformity  when  asso- 
ciated with  scoliosis. 

As  a  general  rule,  this  deformity  is  due  to  rickets,  but  it  may  result  from 
Pott's  disease,  and  also  from  paralytic  conditions.  Where  it  is  the  result  of 
rickets,  the  sternal  bone  projects  the  entire  length  of  the  chest,  increasing  the 
effect  of  the  "rachitic  rosary."  The  entire  thorax  bends  upon  pressure.  Pos- 
teriorly the  ribs  do  not  change  their  direction,  but  at  about  12  or  15  cm.  from 
their  attachment  they  curve  suddenly  and  form  an  internal  angle  at  this  point. 
The  depression  in  the  mid-axillary  region  ceases  at  about  the  ninth  or  tenth 
rib,  where  an  enlargement  of  the  thoracic  walls  occurs  in  order  to  accommodate 
the  distended  abdomen.  This  enlargement  may  continue  after  the  distention 
of  the  abdomen  has  disappeared.  Deformities  of  rachitic  origin  are  due  to 
inequalities  of  external  and  internal  pressure  and  to  the  action  of  the  diaphragm 
and  the  muscles  of  respiration  acting  upon  the  flexible  and  malleable  bones.  Ex- 
ternal pressure  is  an  important  agent  and,  according  to  Redard,  it  is  noticeable 
that  when  children  preserve  the  dorsal  decubitus  the  anteroposterior  diameter 
decreases  and  the  curve  of  the  ribs  increases,  whereas  if  the  dorsal  decubitus 
is  lateral  the  antero-posterior  diameter  is  augmented  while  the  curve  of  the 
ribs  is  diminished.  The  deformity  may  vary  according  to  whether  the  patient 
lies  habitually  on  the  right  or  left  side. 

Deformities  of  the  chest  resulting  from  Pott's  disease  have  already  been 
mentioned  under  that  head. 

Thoracic  deformity  is  a  frequent  result  of  obstruction  of  the  respiratory 
passages.  Chance,  in  600  rachitic  cases  found  156  instances  of  deformity 
resulting  from  nasal  or  post-nasal  obstruction,  spasm  of  the  larynx,  and  nasal 
polypi.  This  variety  of  deformity  consists  in  an  arching  and  narrowing  of  the 
chest  at  the  lower  portion,  and  an  excavation  of  the  sides,  showing  at  about 
the  center  of  the  arch  two  transverse  furrows  caused  by  the  depression  of  the 
middle  section  of  the  ribs.  The  antero-posterior  diameter  increases  while 
the  transverse  diameter  decreases,  especially  at  the  base.  In  some  instances 
the  entire  thorax  seems  to  have  undergone  an  arrest  of  growth,  and  the  contrast 
to  the  development  of  the  neighboring  regions  is  striking. 


NON-TUBERCULOUS  DISEASES  OF  THE  SPINE.  293 

This  variety  of  deformity  is  present  in  infancy  when  there  exists  respiratory 
obstruction,  and  it  is  hable  later  to  be  followed  by  kyphosis  and  scoliosis,  during 
the  principal  period  of  growth,  up  to  the  sixteenth  year,  as  a  consequence  of 
chronic  inflammations  and  affections  of  the  nasopharyngeal  organs,  so  frequently 
present  at  this  period.  According  to  my  experience,  adenoid  tumors  by  causing 
nasal  obstruction  are  an  almost  invariable  cause  of  deformity  of  the  chest. 
Hypertrophy  of  the  tonsils,  to  which  Dupuytren,  Cooper,  Forster,  Coulson, 
and  Warren  have  attributed  thoracic  deformity,  plays  an  unimportant  part, 
at  least  in  so  far  as  it  is  seldom  accompanied  by  adenoid  growths.  Nasal 
hypertrophy  with  chronic  atrophic  rhinitis,  enlarged  tonsils,  deviation  with 
hypertrophy  of  the  wall  of  the  septum,  and  the  osseous  sinking  of  the  posterior 
orifice  of  the  nasal  fossas,  may  also  be  complicated  by  changes  in  the  form 
of  the  chest.  In  consequence  of  the  nasal  obstruction  and  of  insufficient  res- 
piratory action,  with  imperfect  development  of  the  chest  during  respiratory 
movements,  the  chest  cannot  dilate  properly,  and  deformity  results. 

According  to  Redard,  deformities  of  the  chest  and  of  the  spine  which 
result  from  nasal  obstruction  present  none  of  the  general  characteristics  of 
rickets,  but  the  nasal  obstruction  sometimes  met  with  in  rachitic  subjects  may 
play  some  part  in  the  thoracic  deformity  common  to  this  affection,  the  ribs 
and  sternum,  by  reason  of  their  flexibility  and  malleability,  offering  favorable 
conditions  to  the  development  of  deformity  as  a  result  of  these  chronic  affections. 
In  very  young  children  showing  multiple  rachitic  lesions  these  deformities 
are  produced  rapidly  and  at  a  very  early  age,  which  would  differentiate  them 
from  thoracic  deformities  due  to  obstruction  of  the  respiratory  passages,  which 
develop  slowly  and  are  usually  found  in  adolescence. 

Deformities  of  the  chest  have  been  known  to  follow  spasm  of  the  glottis 
and  the  paralytic  conditions  resulting  from  whooping-cough.  They  mav 
also  follow  chronic  affections  of  the  pleura  and  hypertrophy  of  the  heart,  and 
are  characterized  by  the  projection  or  depression  of  the  chest  according  to 
the  period  of  the  disease.  Deformities  following  pleurisy,  especially  those  fol- 
lowing pleuropneumonia  or  empyema  (sunken  chest  of  Laennec),  often  produce 
complex  results  from  the  retraction  of  the  pleura  and  lung,  from  insufficient 
respiration,  from  the  immobilization  of  one  of  the  sides  of  the  chest,  from  neuritis, 
and  from  atrophy  of  the  neighboring  muscles.  The  thoracic  deformity  in 
these  cases  is  frequently  the  cause  of  a  resultant  spinal  deviation. 

Deformity  sometimes  results  from  paralysis  or  atrophy  of  the  muscles 
of  the  chest.     In  progressive  muscular  atrophy  in  infancy,  or  in  adults,  the 


294  ORTHOPEDIC  SURGERY. 

anterior  thoracic  wall  becomes  flattened  and  sometimes  concave,  the  antero- 
posterior diameter  is  diminished,  and  the  sternum  forms  a  sort  of  furrow,  the 
costal  cartilages  forming  the  lateral  walls. 

Prognosis. — The  prognosis  in  deformity  of  the  chest  varies  according 
to  the  cause  and  extent  of  the  deformity,  and,  as  a  rule,  is  favorable  only  when 
the  treatment  is  undertaken  at  a  very  early  stage  of  the  affection.  Certain 
varieties  have  a  very  deleterious  effect  upon  the  heart  and  lungs,  and  the  con- 
traction of  the  diaphragm,  and  consequent  insufficient  respiration,  has  a  very 
injurious  effect  upon  the  general  health. 

Treatment. — The  treatment  should  consist  chiefly  in  removing  the  primary 
cause  of  the  deformity.  In  cases  of  rachitic  origin  it  should  be  the  same  as 
for  rickets,  and  in  those  resulting  from  nasal  obstruction  the  respiratory  organs 
should  first  be  carefully  treated. 

Funnel  chest  is  not  very  amenable  to  treatment,  but  improvement  may 
be  derived  from  care  as  to  hygiene,  exercise,  and  diet.  Phosphorus,  i  :  loo 
to  I  :  150  t.  i.  d.,  is  beneficial,  and  lime,  alone  or  combined  with  phosphoric 
acid,  has  been  found  of  value,  as  has  been  the  use  of  cod-liver  oil  rubbed  into 
the  legs  and  abdomen.  Arsenious  acid  and  iron  will  also  be  found  beneficial. 
Flat  chest,  especially  the  form  resulting  from  avocation,  is  irremediable 
unless  the  occupation  be  changed  early,  but  some  advantage  may  be  had  by 
employing  treatment  similar  to  that  employed  in  round  shoulders. 

Pigeon  breast  should  be  treated  principally  by  manipulation,  massage, 
breathing  exercises,  and  gymnastics,  in  order  to  stimulate  the  respiratory 
muscles. 

Scoliotic  conditions  resulting  in  thoracic  deformity  should  receive  the 
same  treatment  as  that  advocated  for  scoliosis.  When  kyphosis  is  present, 
the  improvement  is  not  satisfactory,  but  undue  pressure  of  the  bands  upon 
the  spinal  support  should  be  corrected  where  it  is  possible.  In  incipient  hollow 
chest  from  atony  of  the  spinal  muscles  exercises  should  be  given  and  the  use 
of  a  shoulder  brace  will  be  found  beneficial. 

In  all  cases  of  thoracic  deformity  gymnastic  exercises  are  especially  valuable 
in  order  to  develop  the  muscles  of  the  chest  and  back,  and  also  the  respiratory 
muscles.  Th6  movements  may  be  both  passive  and  active.  Electricity  is 
of  marked  value  in  some  conditions.  The  expansion  and  development  of  the 
chest  and  back  muscles  being  the  main  object  of  the  treatment,  all  injurious 
external  pressure  should  be  carefully  guarded  against,  such  as  the  wearing 
of  apparatus  which  may  compress  the  chest,  and  particularly  should  corsets 
be  avoided. 


CHAPTER  III. 
SACRO-ILIAC  DISEASE. 

Sacro-iliac  disease  is  an  acute  or  chronic  tuberculous  affection  of  the  sacro- 
iliac articulation. 

Synonyms. — English,  Sacro-coxitis  (Hueter);  Sacrarthrocace.  French, 
Sacrocoxalgie.    Italian,  Malo  di  Boyer.    Spanish,  Mai  sacroiliac. 

This  disease  is  fortunately  uncommon,  although  probably  more  com- 
mon than  is  generally  supposed.  Existing  apart  from  spondylitis  in  the  lower 
lumbar  spine,  it  is  of  rare  occurrence.  The  first  accurate  account  of  the  affection 
was  made  by  Boyer,  in  1821,  since  which  numerous  theses  and  monographs 
have  been  written,  the  best  being  those  by  Hahn,  Nelaton,  Erichsen,  and  Van 
Hook. 

Etiology. — It  is  an  affection  of  early  adult  life,  but,  as  Velpeau  remarked, 
it  is  met  "at  all  ages,  in  private  and  hospital  practice,  among  the  rich  and  poor. " 
The  negro  race  is  not  exempt,  as  the  writer  has  observed  a  t)rpical  case  in  a 
young  mulatto  woman.  Poore  reports  cases  which  he  has  seen  in  children. 
It  is,  however,  rare  in  children.  Thus,  according  to  Van  Hook,  in  thirty- 
two  cases  in  which  the  age  was  recorded,  "less  than  22  per  cent,  of  the  cases 
were  below  fifteen  years  of  age;  the  same  proportion  were  between  fifteen 
and  twenty  years  of  age;  while  in  the  fifth  lustrum  of  life  we  find  twelve  cases 
recorded,  just  375  per  cent,  of  the  whole  number.  All  the  remaining  years 
of  life  furnish  only  six  cases."  Added  to  a  specific  constitutional  predis- 
position, the  exciting  cause  is  usually  found  in  exhaustion,  exposure,  or  trau- 
matic violence.  One  case  directly  due  to  injury  is  recorded  by  Louis. 
Among  the  cases  recorded  were  gunners,  exposed  to  the  sudden  jars  of  jolt- 
ing caissons;  laundresses,  and  children  addicted  to  violent  sports.  Young 
cavalry  soldiers  are  often  subjected  to  this  disease,  the  exciting  cause  being 
the  traumatism  from  the  equestrian  exercise,  the  sacro-Uiac  joint  in  this  ex- 
ercise being  obliged  to  bear  the  entire  weight  of  the  trunk.  Sex  is  an 
element,  but  the  greater  exposure  of  males  to  traumatism  is  partially  offset 
by  the  greater  liability  of  parturient  women. 

Pathology. — The   lesions   are   identical   with   tuberculous   joint   disease 


296 


ORTHOPEDIC  SURGERY 


elsewhere.  The  affection  may  begin  in  the  synovial  membrane  or  bone, 
and  extend  rapidly  to  the  cartilaginous  constituents  of  the  articulation.  Dis- 
ease of  the  bones  is  far  more  frequently  met  than  that  of  other  structures, 
and  on  account  of  the  strength  and  thickness  of  the  posterior  ligaments,  and 
the  absence  of  definite  subjective  symptoms  in  an  early  case  it  is  rarely  recog- 
nized before  suppuration  has  occurred  or  the  bone  has 
become  considerably  involved.  The  anatomic  con- 
struction and  pathologic  features  most  resemble  Pott's 
disease  of  the  vertebra,  as  pointed  out  by  Delens. 
Tubercular  foci  and  sequestra  are  formed,  and  masses 
of  bone  may  be  discharged  per  rectum.  Granulation 
tissue  may  form  in  the  bone,  or,  invading  the  soft 
tissues,  give  rise  to  abscess  formation.  The  inflamma- 
tion is  more  often  of  the  caries  necrotica  than  of  the 
caries  sicca  t)^e,  two  varieties  distinguished  by  Konig 
as  a  "moist  form"  and  a  "dry  granulating  form." 

Symptoms. — The  cardinal  symptoms  of  sacro- 
iliac disease  are  five,  in  the  order  of  succession  as 
follows :  pain,  lameness,  changes  in  attitude  and  length, 
tumefaction,  and  abscess.  The  pain,  at  first  inter- 
mittent or  fugitive,  becomes  in  time  constant  and 
severe.  It  varies  in  situation  and  may  be  referred  to 
the  course  of  the  sciatic  nerve.  The  local  pain  in 
sacro-iliac  disease  is  a  shooting  pain  in  the  median 
line  of  the  affected  region,  radiating  outward  to  the 
remote  distribution  of  the  dorsal  nerves.  This  pain 
occurs  usually  on  arising  from  bed  after  a  night's 
repose,  and  frequently  passes  off  within  five  minutes 
after  the  patient  has  begun  to  move  about.  It  is 
aggravated  by  coughing,  laughing,  urination,  or  defeca- 
tion, and  pressing  the  sides  of  the  pelvis  together  pro- 
duces pain  in  the  joint,  a  symptom  almost  pathognomonic.  The  pain  is  often 
accompanied  by  the  sensation  as  if  the  body  was  falling  apart.  Sensitiveness  upon 
pressure  is  present  posteriorly  and  may  be  elicited  anteriorly  per  rectum.  After 
abscesses  have  formed,  the  pain  may  radiate  to  the  anus,  the  leg,  or  extend  to  the 
knee.  On  account  of  the  peculiar  anatomic  characters  of  the  joint,  muscular 
spasm  and  atrophy,  such  common  and  prominent  symptoms  in  affections  of  other 


Fig.  287. — Sacro-iliac  Dis- 
ease, SHOWING  Charac- 
teristic Attitude. 


SACRO-ILIAC  DISEASE. 


297 


joints,  are  not  conspicuous,  but  atrophy  of  the  muscles  of  locomotion  occurs.  In 
walking  the  gait  is  very  cautious,  all  jar  is  avoided,  and  hence  the  patient  walks 
mainly  upon  the  ball  of  the  foot  and  never  upon  the  entire  sole.  Lameness 
occurs  early,  walking  is  difficult,  the  diseased  limb  is  favored  as  much  as  pos- 
sible, the  body  is  inclined  to  the  sound  side,  and  the  pelvis  tilted  into  the  so- 
called  "position  hanchee"  of  Hattute,  which  Sayre  regards  as  character- 
istic. Later,  the  patient  becomes  bedridden,  lying  upon  the  unaffected  side. 
The  elongation  of  the  limb  is  apparent  from  downward  rotation  of  the  innom- 


FiG.  288. — Saceo-iliac  Disease. 


inate  bone,  and  not  from  actual  increase  in  length,  a  fact  easily  demonstrated 
by  measurement  between  the  bony  joints.  Swelling  appears  first  over  the  head 
of  the  sacro-iliac  joint,  and  later  extends  to  and  alters  the  shape  of  the  buttocks. 
The  local  temperature  is  elevated,  a  fact  utilized  by  Sayre  for  diagnostic  pur- 
poses. Suppuration  does  not  occur  in  all  cases,  and  when  present  is  most 
common  during  the  late  stages  of  the  affection.  In  fifty-five  collected  cases, 
abscesses  occurred  in  thirty-eight.  When  formed,  abscesses  find  their  exit  in 
the  direction  of  least  resistance,  becoming  at  once  either  intra-pelvic  or  extra- 


298 


ORTHOPEDIC  SURGERY. 


pelvic,  in  the  proportion  of  61.8  per  cent,  of  the  former  to  38.2  per  cent, 
of  the  latter.  The  direction  and  termination  of  these  are  well  sho'wn  in  the 
following  table,  modified  from  Van  Hook : 

TABLE  OF  ABSCESSES  IN  SACRO-ILIAC  TUBERCULOSIS  (AFTER  VAN  HOOK), 
r  Pointing  posteriorly  {i.  e.,  immediately  over  the  joint). 
Extra-pelvic  ]   Dissecting  upveard  (pointing  in  lumbar  region). 

[  Dissecting  downward  (pointing  in  the  gluteal  region). 

Dissecting  upward  to  lumbar  region. 

Under  periosteum. 


-  Intra-pelvic 


Dissecting  outward  and  for- 
ward. 


Dissecting    directly    down- 
ward. 


Under  iliopsoas. 


1.  Out     through     sciatic  | 

notch.  [ 

2.  Inward  toward  ischio- 

rectal fossa  to 


Without  finding  exit 

anteriorly. 
Toward  insertion  of 

iliopsoas. 
Through  gluteus. 
Downward  to  thigh. 
Rectum. 
Perineum  or  anus. 


Diagnosis. — Though  the  diagnosis  of  sacro-iliac  disease  can  usually 
be  readily  made,  there  are  several  affections  with  which  it  may  be  con- 
founded. These  are:  lumbo-abdominal  neuralgia,  sciatica,  lumbago,  psoitis, 
caries  and  necrosis  of  the  iliac  bone,  lumbar  Pott's  disease,  and  hip  disease, 
the  diagnostic  points  of  which  have  already  been  given.  In  addition  to  these, 
it  may  be  remembered  that  this  joint  is  liable  to  many  forms  of  joint  disease 
— acute  and  chronic  suppurative  inflammations,  primary,  osteomyelitic,  and 
metastatic;  acute  articular  and  gonorrheal  rheumatism  and  arthritis  defor- 
mans, and  is  also  the  seat  of  tumors,  fibro-plastic  hydatids,  and  enchondro- 
mas.  Lumbo-abdominal  neuralgia  may  be  distinguished  by  the  superficial 
and  diffused  character  of  the  pain,  its  resemblance  to  other  forms  of  neuralgia, 
and  particularly  by  attention  to  the  painful  points  of  Valleix.  Sciatica  may 
be  recognized  by  its  occurrence  in  older  persons,  the  situation  of  the  pain  below 
and  not  above  the  gluteal  muscles  and  extending  down  the  back  of  the  thigh, 
slight  flexion  of  the  limb,  deformity  of  the  pelvis,  or  other  signs  of  articular 
disease.  In  lumbago  the  tenderness  is  over  the  lumbar  region,  not  over  the 
joint;  it  is  bilateral  in  distribution,  increased  by  flexion  and  extension  of  the 
trunk,  and  unaccompanied  by  any  symptoms  of  the  disease  of  the  sacro-iliac 
joint.  In  psoitis  the  thigh  is  flexed  and  the  foot  rotated  inward;  pain  is  absent 
from  the  posterior  part  of  the  joint,  but  is  caused  by  extension  of  the  thigh,  and 
pressure  upon  the  sides  of  the  pelvis  does  not  elicit  pain.     Caries  and  necrosis 


SACRO-ILIAC  DISEASE.  299 

of  the  ilium  are  to  be  distinguished  by  the  absence  of  pain  in  standing  and 
walking,  elongation  of  the  limb,  and  tilting  of  the  pelvis  on  the  affected  side. 
The  exploration  of  fistulas  will  facilitate  the  diagnosis.  Lumbar  Pott's  disease 
offers  a  condition  which  is  very  confusing,  and  one  best  distinguished  by  its 
occurrence  during  childhood,  the  presence  of  spinal  deformity,  of  tenderness 
over  the  affected  area,  with  general  rigidity  of  the  spinal  column,  and  absence 
of  elongation  or  other  symptoms  of  disease  of  the  sacro-iliac  articulation.  There 
is  no  lameness  in  walking. 

Prognosis. — The  prognosis  of  advanced  sacro-Uiac  disease  has  always 
been  considered  unfavorable,  a  fatal  result  usually  occurring  from  long-continued 
suppuration  and  hectic  fever,  and  secondary  tuberculosis.  Among  cases  seen 
earlier,  recoveries  were  recorded.  It  is  to  be  considered,  however,  that  the 
symptoms  detailed  of  many  non-suppurative  cases  hardly  warrant  the  diagnosis 
of  sacro-iliac  tuberculosis,  and  by  that  much  detract  from  the  weight  which 
they  would  otherwise  give  to  a  favorable  prognosis;  and  that  the  fatal  termination 
and  consequently  unfavorable  prognosis  of  the  suppurative  cases  have  more 
frequently  been  due  to  the  character  of  the  operative  interference  than  to  the 
nature  of  the  affection.  There  seems  to  be  no  good  reason  for  believing  that 
tuberculosis  of  the  sacro-iliac  articulation  is  governed  in  its  fatalities  by  other 
laws  than  those  which  govern  the  fatalities  in  tuberculosis  of  other  joints.  As 
in  spondylitis,  deaths  occur  from  tubercular  infection  of  other  organs  quite 
as  frequently  in  the  dry  as  in  the  moist  form  of  disease,  provided  there  be  no 
operative  interference.  Death  from  prolonged  suppuration  is  exceedingly 
rare  when  tubercular  abscesses  are  subject  to  the  let-alone  treatment,  and 
rarer  still  is  death  from  septic  infection.  On  the  other  hand,  there  can  be  no 
reasonable  doubt  that  any  operative  interference  increases  the  risk  of  general 
tubercular  infection;  and  unless  the  operation  be  strictly  aseptic,  and  the 
prolonged  subsequent  dressings  be  kept  so,  the  risk  of  septic  infection  of  a 
large  cavity  connected  with  carious  bone  is  considerable. 

The  prognosis  in  children  is  much  better  than  in  adults. 

Modern  statistics  indicate  a  strong  tendency  to  an  unfavorable  prognosis 
in  the  moist  variety,  but  a  decidedly  favorable  tendency  in  the  dry  granulation 
form.  Thus,  in  i6  out  of  17  cases  in  which  abscesses  did  not  occur,  the  recov- 
eries were  94  per  cent.,  while  in  38  cases  in  which  abscesses  occurred,  the 
recoveries  without  operation  were  only  3,  or  7.9  per  cent. 

Treatment. — The  proper  treatment  will  depend  upon  the  stage  in  which 
the. disease  is  recognized  and  the  variety  of  the  affection.     Whether  of  the 


300  ORTHOPEDIC  SURGERY. 

dry  granulation  type,  or  the  moist  form  with  abscess  formation,  in  either  the 
hygienic  conditions  should  be  the  best  that  circumstances  permit,  and  the 
general  health  should  be  sustained  and  improved  by  stimulants,  tonics,  etc. 
In  the  early  stage  the  joint  should  be  immobilized  with  plaster-of-Paris,  leather, 
or  some  other  form  of  apparatus,  and  the  patient,  placed  on  crutches,  wearing 
a  high  shoe  upon  the  foot  of  the  sound  side,  may  enjoy  the  benefits  of  fresh 
air  and  sunshine.  Extension  by  weight  and  pulley  should  be  employed  at  night, 
and  later  may  be  used  constantly  with  the  patient  in  the  recumbent  position. 
When  the  pain  is  severe,  counter-irritation  with  iodin,  cantharidal  collodion, 
or  thermocautery  is  indicated.  When  abscesses  form,  they  should  be  freely 
opened  and  thoroughly  drained,  and  any  sequestra  found  should  be  removed 
and  the  walls  thoroughly  cureted,  the  object  being  to  remove,  if  possible,  all 
tuberculous  matter.  Drainage  is  best  effected  with  iodoform  gauze,  and  full 
aseptic  precautions  should  be  observed.  If  the  abscesses  be  intra-pelvic 
alone,  the  disease  may  be  reached  without  the  extensive  removal  of  healthy 
bone  required  in  the  operation  of  Tiling,  by  employing  the  method  of  Van  Hook. 
A  vertical  incision,  two  or  three  inches  in  length,  over  the  posterior  spinous 
process  of  the  ilium  is  first  made,  the  bone  is  denuded  of  periosteum  and  connec- 
tive tissue  by  scraping,  and  with  a  chisel  small  fragments  are  removed  from  the 
exposed  bone  until  the  anterior  surface  of  the  diseased  joint  can  be  exposed  and 
thoroughly  cureted  with  curved  instruments.  Iodoform  gauze  packing  and 
an  aseptic  dressing  complete  the  operation.  Severe  cases  may  demand  excision 
of  the  sacro-iliac  synchondrosis. 


CHAPTER  IV. 
HIP-JOINT  DISEASE. 

Hip-joint  disease  is  a  chronic  tubercular  lesion  of  the  coxofemoral 
articulation,  beginning  usually  as  an  osteitis  or  synovitis  and  terminating  in 
recovery,  ankylosis,  or  complete  destruction  of  the  joint. 

Synonyms. — English,  Morbus  Coxarius;  Morbus  Coxae;  Hip  Disease; 
Tuberculous  Disease  of  the  Hip ;  Chronic  Articular  Osteitis  of  the  Hip ;  Chronic 
Epiphysitis  of  the  Hip;  Medullo- Arthritis ;  Coxalgia;  Coxitis;  Morbo-coxario. 
French,  Coxo-tuberculose ;  Coxalgie;  Coxarthrocace ;  Femoro-coxalgie ;  Cox- 
opathie.  Italian,  Malocoxario,  Coxiti,  or  Coxotuberculosi.  Spanish,  Coxo- 
tuberculosis. 

Many  of  these  terms  are  misleading  or  at  most  unsatisfactory.  The  term 
here  used,  hip-joint  disease,  is  now  accepted  by  common  usage,  but  for  scientific 
purposes  the  terms  chronic  articular  osteitis  (Gibney),  or  coxo-tuberculose 
(Lannelongue),  would  best  suit  the  purpose. 

Frequency. 

The  frequency  of  hip-disease  in  surgical  practice  is  illustrated  in  the  fact 
that  in  looo  cases  of  tuberculous  bone  disease  collected  by  me  421  were  cases  of 
this  affection,  and  the  relative  number  of  cases  of  hip  disease  compared  to 
diseases  of  the  other  articulations  is  shown  in  the  following  list  of  cases  from 
the  same  source: 


Vertebras, 416 

Hip-joint, 421 

Knee-joint, 103 

Ankle-joint, 33 

Shoulder-joint, 2 

Elbow-joint, 17 

Wrist-joint, 8 


6  per  cent. 
I         " 
3 
3 


1000  100   per  cent. 

Of  the  7932  cases  admitted  to  the  Children's  Hospital  of  Philadelphia, 
592  were  cases  of  hip-joint  disease.  Of  the  two  sides,  the  right  limb  appears 
to  be  more  frequently  affected:     thus  Whitman  found  that  53  per  cent,  were 

301 


302  ORTHOPEDIC  SURGERY. 

on  the  right  side,  and  in  my  own  statistics  52.7  per  cent,  were  on  the  right, 
and  47.3  on  the  left. 

Bilateral  Hip  Disease. — It  affects  usually  but  one  side,  but  instances  of 
double  hip  disease  occur.  Thus  Whitman  found  11  cases  in  1000  cases  of 
hip  disease,  and  in  my  own  statistics  in  421  hip  cases  there  were  18  double 
cases;  of  these,  12  occurred  in  males  and  6  in  females. 

Etiology. 

The  causes  of  hip  disease  are  both  predisposing  and  exciting.  The  age, 
sex,  heredity,  hygienic  surroundings  and  social  condition,  and  the  peculiar 
anatomy  of  the  joint  are  all  predisposing  factors;  the  exanthemata  of  childhood, 
traumatism,  and  diseases  of  the  neighboring  organs  being  exciting  causes. 

Age. — Though  occurring  later  in  life  in  exceptional  instances,  hip  disease 
is  essentially  a  disease  of  infancy  and  childhood,  and  age  may  be  considered 
one  of  the  most  important  predisposing  factors. 

Congenital  cases  have  been  observed  and  reported  by  Broca,  Verneuil, 
Morel-Lavellee,  and  Padieu.  All  observers  report  occasional  cases  during 
the  first  year,  but,  as  a  rule,  hip  disease  attacks  children  between  the  ages  of 
two  and  thirteen  years.  Thus,  of  365  cases  collected  by  Sayre,  221  were  under 
fifteen  years  and  121  of  these  were  under  five  years;  of  360  cases  collected  by 
Bryant,  309  were  under  twenty  years,  and  of  these  126  were  under  four  years; 
of  6ig  cases  collected  by  Wright,  480  were  under  fifteen  years,  and  of  these 
130  were  under  six  years;  of  860  cases  reported  by  Gibney,  84^  per  cent,  of 
all  cases  occurred  before  fourteen.  Of  my  own  statistics  of  421  cases,  351 
occurred  before  the  fifteenth  year,  and  273  of  these  before  the  tenth  year.  They 
were  distributed  as  follows: 

Less  than  i  year, S 

Between  i  and  5, 132 

Between  6  and  10, 136 

Between  11  and  15, 78 

Between  16  and  20, 29 

Between  20  and  25, 17 

Between  26  and  30, 13 

Between  31  and  35 7 

Between  36  and  40, 4 

Between  41  and  45, 3 

Between  46  and  50, 2 

After  50, o 

The  relative  frequency  of  hip  disease  at  this  early  period  is  probably  due 
to  the  following  causes:    the  frequency  of  tuberculosis  in  childhood;    the  active 


'     '  HIP-JOINT  DISEASE.  303 

growth  and  immature  nature  of  the  epiphyses  and  joint  constituents  generally; 
the  greater  liability  of  children  to  fall;  the  greater  bodily  activity  of  youth, 
which  favors  the  development  of  grave  disease  from  slight  injury. 

As  there  is  usually  some  lapse  of  time  between  the  occurrence  of  the  injury 
and  the  onset  of  the  disease,  it  is  interesting  to  note  the  various  periods  which 
may  elapse  in  a  series  of  cases.  I  have  collected  loo  consecutive  cases  of  hip- 
joint  disease  from  the  case-books  of  the  Hospital  of  the  University  of 
Pennsylvania,  which  show  the  following: 

(o)  Within  two  weeks, 43 

(6)  Two  weeks  to  three  months, 28 

(c)  Three  to  six  months, 15 

{d)  Six  months  to  one  year, 7 

(e)   One  year  to  eighteen  months, 6 

(/)   Longest  period  three  years, i 

100  cases. 

Instances  of  primary  hip  disease  after  twenty-five  years  are  rare.  Wright 
has  recorded  one  occurring  at  fifty-four  years,  and  Paget  has  pointed  out  the 
fact  that  people  over  sixty  are  more  often  "scrofulous"  than  people  between 
thirty  and  fifty,  and  referred  to  the  frequency  of  hip-joint  disease  in  the  aged. 
Relapses,  particularly  between  thirty  and  forty  years  of  age,  are  common. 

Sex. — Though  sex  is  considered  by  most  modern  writers  to  be  of  no 
importance  as  an  etiologic  factor,  the  greater  number  of  males  over  females 
in  all  statistics  remains.  Thus,  according  to  Ashhurst,  of  100  cases  admitted 
into  the  Children's  Hospital  of  Philadelphia,  61  were  boys  and  43  were  girls; 
and  Lannelongue  found  in  100  cases  57  boys  and  43  girls.  Likewise,  of  619 
cases  recorded  by  Wright,  371  were  males.  Whitman  in  his  1000  cases  found 
553  (S5-3  psr  cent.)  males,  and  447  (44.7  per  cent.)  females,  and  in  my  own 
statistics  of  421  cases,  247,  or  58.7  per  cent.,  were  males,  and  174,  or  41.3  per 
■  cent.,  were  females.  This  preponderance  of  males  over  females  among  patients 
suffering  from  hip  disease  has  been  assigned  to  two  causes:  the  greater  liability 
of  males  to  injury  from  their  more  boisterous  habits,  and  the  existence  of  phimosis 
as  an  exciting  cause.  The  former  will  be  considered  under  the  exciting  causes; 
but  the  latter,  since  it  concerns  the  sexes  directly,  may  be  given  here. 

Barwell  many  years  ago  observed  a  singular  coincidence  between  lup 
disease  and  phimosis,  and  reported  that  in  100  cases  examined  in  6  only  was 
there  no  phimosis;  66  had  the  affection  severely,  and  28  slightly. 

Since  this  report,  Sayre,  Wright,  and  others  have  found  it  as  one  of  the 
exciting  causes  of  hip  disease. 


304  ORTHOPEDIC  SURGERY. 

It  has  also  been  suggested  that  Hebrew  boys  were  particularly  liable  to 
inoculation  of  tuberculosis  during  the  ceremony  of  circumcision,  as  has  been 
referred  to  under  the  general  subject  of  tuberculosis  in  Part  I;  but  since  the 
introduction  of  antiseptic  methods  among  the  surgeons  this  danger  may  be 
considered  overcome.  While  the  danger  is  more  frequent  among  males,  sex 
has  but  little  influence  as  a  predisposing  cause. 

Heredity. — The  difficulty  of  correctly  ascertaining  the  influence  of 
inherited  disease  is  at  once  evident  when  we  realize  the  inclination  of  both 
parents  and  patients  to  deny  the  existence  of  tuberculous  disease  in  their  ances- 
tors or  near  relatives,  and  their  desire  to  establish,  if  possible,  a  traumatic  origin 
for  the  affection. 

For  example,  out  of  my  looo  cases  of  tuberculous  joint  disease  before  re- 
ferred to  there  was:  Hereditary  predisposition,  240,  or  24  per  cent.;  traumatic 
predisposition,  298,  or  29.8  per  cent.;  acquired  predisposition,  462,  or  46.2 
per  cent* 

For  this  reason  the  greater  proportion  of  statistics  are  inaccurate  and 
only  approximate  the  truth,  the  error  being,  however,  on  the  side  against 
inheritance.  Notwithstanding  this,  both  experimental  research  and  clinical 
investigation  tend  to  establish  the  tuberculous  tendency  as  a  predisposing  cause. 
The  direct  transmission  of  tuberculosis  has  been  established.  This  subject 
has  been  considered  under  the  etiology  of  tuberculous  joint  disease — Part 
I.  Clinical  analyses  of  hip-joint  cases  have  variously  estimated  the  percentage 
of  patients  who  have  either  a  hereditary  or  an  acquired  diathesis.  Gibney, 
after  a  careful  analysis  of  596  cases  of  tubercular  joint  disease  of  the  different 
joints,  of  which  265  were  diseases  of  the  hip-joint,  could  find  only  one  case 
which  did  not  present  either  an  inherited  or  acquired  diathesis.  Of  these 
265  cases,  phthisis  occurred  in  the  father's  family  53  times,  in  the  mother's 
56;  and  diseases  unquestionably  tubercular  in  the  fathers  10,  and  in  the  mothers 
18  times,  besides  the  syphilitic,  rheumatic,  and  alcoholic  diathesis  a  number 
of  times. 

Traumatism. — The  injuries  which  are  most  frequently  followed  by  tuber- 
culosis of  the  hip  is  a  fall  from  a  height,  the  patient  alighting  with  the  feet  widely 
separated,  producing  an  injury  to  the  round  ligament  or  head  of  the  bone, 
and  a  lateral  fall,  striking  on  the  trochanter;  occasionally  the  exciting  cause 
is  a  severe  twist  of  the  hip  produced  by  the  foot  being  caught  and  the  person 
being  suspended  and  wrenched  by  the  fall. 


HIP- JOINT  DISEASE.  305 

Pathology. 

Though  hip  disease  is  fatal  in  a  certain  number  of  cases,  the  opportunity 
for  anatomic  study  at  an  early  period  is  rarely  offered,  hence  the  contradictory 
statements  which  exist  in  regard  to  the  seat  of  the  initial  lesion.  The  pathologic 
lesion  in  the  advanced  stage  is  a  destructive  tubercular  osteitis,  resulting  in 
interstitial  absorption  or  caries  of  a  portion  or  the  entire  constituents  of  the 
joint,  and  as  a  tuberculous  lesion  it  does  not  differ  from  tuberculous  osteitis 
elsewhere,  and  will  be  found  fully  described  under  Part  I.  A  sufficient  number 
of  early  autopsies  have  fortunately  been  observed  to  settle  definitely  the  fact 
that  the  initial  lesion  may  originate  in  any  one  of  the  structures  which  constitute 
the  articulation,  occurring  more  frequently  in  certain  localities  than  in  others. 
Thus  in  a  case  reported  by  Agnew,  of  a  lad  suffering  from  incipient  coxalgia, 
who  died  of  tuberculous  meningitis,  the  inflammatory  redness  occupied  the 
cartilage  a  short  distance  round  the  acetabular  and  femoral  attachment  of  the 
ligamentum  teres.  Holmes  also  reports  two  autopsies  in  incipient  coxalgia, 
in  which  he  noted  inflammatory  lesions  of  the  s3movial  membrane  and  round 
ligament,  and  one  of  erosion  of  the  ligament.  Marjolin  and  Gosselin,  Martin 
and  Collineau,  report  similar  cases.  Autopsies  at  a  later  period  of  the  disease 
show  the  head  of  the  femur  and  acetabulum  frequently  involved,  but  as  far  as 
known  there  are  no  specimens  recorded  of  initial  lesion  of  the  acetabulum, 
it  being  usually  secondarily  affected. 

In  6 1  specimens  of  hip  excision  analyzed  by  Miiller,  it  was  found  that 
the  disease  began  in  the  bone  in  47  cases,  in  the  synovial  membrane  in  3,  but 
it  was  impossible  to  state  where  it  originated  in  3. 

According  to  Habern,  from  an  analysis  of  132  hip  resections  in  Volkmann's 
clinic,  primary  acetabular  infection  is  more  frequent.  Thus,  a  caseous  focus 
of  the  acetabulum  was  found  in  50,  with  a  sequestrum  in  31 ;  a  focus  was  found 
in  the  femoral  head,  neck,  or  trochanter  in  23;  foci  in  both  acetabulum  and 
femur  in  7;  and  the  disease  was  so  far  advanced  in  29  that  it  was  impossible 
to  locate  the  primary  lesion.  While  Nichols  believes  that  the  foci  in  the  bone 
preceded  the  joint  lesion  in  all  of  the  120  tuberculous  joint  specimens  examined 
by  him,  all  systematic  writers  describe  a  primary  synovial  form  of  tuberculosis 
occurring  in  from  16  to  35  per  cent.,  and  it  is  the  common  belief  among  ortho- 
pedic surgeons  that  the  tuberculosis  may  be  primarily  synovial. 

The  majority  of  surgical  authorities  at  the  present  time  believe  in  the 
osseous  origin  of  chronic  tuberculous  osteitis,  while  a  few  still  cling  to  the 
theory  of  a  purely  synovial  origin. 


306  ORTHOPEDIC  SURGERY. 

The  origin  of  hip  disease  from  a  psoas  abscess  or  from  a  tuberculous  adenitis 
is  primarily  synovial  by  contiguity  of  structure.  The  recorded  cases  of  primary 
infection  of  the  ligamentum  teres  are  sufficient  to  establish  the  occasional  primary 
ligamentous  origin  of  the  affection.  In  adults  a  synovitis  may  terminate  in 
a  tuberculous  arthritis.     With  these  exceptions  personal  observation  confirms 


Fig.  289. — Skiagraph  of  Unilateral  Hip-joint  Disease. 

the  statement  of  Lannelongue,  that  in  the  majority  of  instances  "la  coxo-tuber- 
culose  est  primitivement  osseuse";  a  statement  more  recently  confirmed 
by  the  pathologic  studies  of  Nichols. 

The    microscopic    appearance    resembles    tubercular    osteitis    elsewhere. 
Its  extent  and  destructiveness  will  depend  somewhat  upon  the  initial  lesion 


HIP-JOINT  DISEASE. 


307 


and  the  virulence  of  the  process.  In  the  head  and  neck  of  the  femur  the  lesion 
may  be  limited  to  a  circumscribed  area;  the  epiphysis  may  be  completely 
destroyed,  separated,  and  lying  loose  within  the  joint — in  the  latter  the  sequestra 
being  cut  off  by  granulation  tissue,  the  process  being  a  caries  necrotica.     In 


Fig.  290. — Skiagraph  of  Bilateral  Hip-joint  Disease. 


rare  instances  the  entire  cartUage  is  separated  and  raised  up  like  a  hood  by 
the  formation  of  fungous  granulation  tissue  beneath.  When  the  inflammation 
commences  in  the  sound  ligament  microscopic  section  shows  active  proliferation 
of  the  cartilage  cells  at  the  insertions  of  the  ligament  to  the  acetabulum  and 
to  the  head  of  the  bone,  gradually  extending   to   the   cartilage   and   to   the 


308 


ORTHOPEDIC  SURGERY. 


bone.  In  the  acetabular  variety  the  cartilage  is  frequently  infected  secondarily 
from  contiguity  of  structure  from  the  diseased  head  of  the  bone  in  contact 
with  it. 

In  the  severer  forms  all  the  components  of  the  joint  are  infected  and 
destroyed.  The  synovial  membrane,  at  first  thickened,  ultimately  disappears, 
the  head  and  neck  become  carious  and  have  a  "  vv^orm-eaten "  appearance 
or  these  portions  may  entirely  disappear;  the  acetabulum  is  excavated 
or  entirely  perforated  by  the  ulcerative  process.  True  dislocation  seldom 
occurs.     The  absorption  of  the  cavity  by  ulceration  and  new  bone  formation 

around  the  acetabulum — the  so- 
called  "traveling  acetabulum"  so 
characteristic  of  the  disease — have 
given  rise  to  this  impression.  A 
true  dislocation  is,  however,  possi- 
ble by  the  head  of  the  bone  being 
pushed  out  of  the  acetabulum  by 
a  tuberculous  mass  within  its 
cavity. 

In  those  cases  of  osteitis  in 
which  interstitial  absorption  oc- 
curs— caseation  without  suppur- 
ation— a  residual  abscess  may  re- 
sult. In  this  form  of  inflammation 
— the  so-called  caries  sicca — the 
affection  may  exist  for  years  with 
extensive  destruction  of  the  carti- 
lages and  bones,  with  consecutive  dislocation  but  without  a  drop  of  pus. 
In  such  the  granulations  are  firmer,  almost  cartilaginous  in  consistence, 
tending  to  atrophy  and  cicatrization — a  process  analogous  to  cirrhosis. 
In  a  large  proportion  of  cases,  where  the  disease  runs  its  course  un- 
checked by  treatment,  suppuration  occurs,  the  abscesses  finding  exit  in  the 
direction  of  least  resistance,  their  course  and  termination  being  comparatively 
uniform. 

Profuse  suppuration  from  the  joint  is  always  a  sign  that  part  of  the  s}'novial 
membrane  has  not  yet  been  destroyed,  or  that  there  are  large  abscesses  near 
the  joint;  the  secretion  from  fungous  granulations  is  less  abundant,  serous  or 
mucous.     Periarticular  abscesses,  and  suppuration  of  the  cellular  tissue  about 


Fig.  201. — Tuberculosis  of  Head  of  Feiich  (Krause) 
ii.  Separation  of  cartilage  in  form  of  hood. 


HIP-JOINT  DISEASE.  309 

the  joint,  whether  associated  with  the  joint  disease  or  independent  of  it,  increase 
the  amount  of  discharge. 

The  disease  may  halt  and  recover  at  any  stage.  If  the  disease  terminate 
before  the  articulation  has  suffered  much  mutilation,  it  may  return  by  a  process 
of  repair  almost  to  its  original  condition.  If  ankylosis  occur,  however,  the 
femur  and  ilium  become  consolidated  and  fixed  by  firm  fibrous  or  bony  union, 
the  articulation  being  protected  against  dislocation  by  an  osteoplastic  osteitis. 

Patients  with  hip  disease  are  exceptionally  attacked  by  phthisis  pulmonalis, 
though  osteitis  of  other  parts  is  common,  as  of  the  vertebras,  tarsus,  carpus, 
elbow-joint,  shoulder-joint,  etc.  When  phthisis  occurs  in  patients  suffering 
from  hip  disease,  there  is  always  a  subsidence  of  the  latter  disease,  and  sinuses, 
if  present,  cicatrize  as  a  result  and  not  as  a  cause  of  the  pulmonary  disease. 

It  is  because  of  this  apparent  antagonism  that  exists  between  the  tubercular 
diseases  that  it  is,  moreover,  unusual  for  two  grave  manifestations  of  tuber- 
culosis to  be  active  at  the  same  time — one  will  become  manifest,  while  the 
other  is  observed  to  improve  or  subside. 

When  the  localized  tubercular  process  in  the  hip-joint  infects  the  general 
system,  tubercular  meningitis  or  general  miliary  tuberculosis  results. 

Symptoms. 

The  symptoms  of  well-established  hip  disease,  taken  together,  are  so 
characteristic  that  the  affection  is  evident  at  a  glance,  and  yet  the  symptoms 
indicating  the  commencement  of  this  disease  are  so  obscure  that  it  is  frequently 
mistaken  for  rheumatism,  and  still  more  frequently  for  knee-joint  disease. 
Distinct  remissions  of  all  the  symptoms  may  occur,  and  these  may  be  repeated 
many  times — in  one  instance  reported  by  Shaffer,*  as  many  as  seven — before 
the  disease  becomes  established. 

It  has  always  been  considered  most  convenient,  for  purposes  of  description, 
to  divide  hip  disease  into  three  stages: 

1.  The  stage  of  onset. 

2.  The  stage  of  apparent  lengthening. 

3.  The  stage  of  real  shortening. 

While  each  stage  represents  definite  groups  of  symptoms  peculiar  to  itself 
and  corresponding  to  the  pathologic  changes  occurring  in  the  joint  in  (i)  the 
stage  of  localized  bone  disease,  (2)  the  stage  of  joint  involvement,  and  (3)  the 


■  "  Tr.  Orth.  .-' ssoc,"  vol.  xv,  p.  258. 


310  ORTHOPEDIC  SURGERY. 

stage  of  destruction  of  the  capsule  and  of  external  suppuration,  it  has  not  been 
deemed  desirable  by  recent  writers  to  make  such  a  division;  but  I  am  of  the 
opinion  that  there  is  nothing  gained  and  much  lost  by  omitting  this  method 
of  classification,  particularly  as  it  describes  the  most  common  form  of  hip  disease. 
This  form  will  be  designated  in  the  following  classification  as  the  chronic 
ulcerative  variety. 

The  pathologic  conditions  embraced  in  the  comprehensive  term  "hip 
disease"  include  a  number  of  well-marked  types.  These  have  been  classified 
by  Lovett*  under  four  heads:  (i)  the  destructive,  (2)  the  painful,  (3)  the 
quiet,  or  painless,  (4)  the  transient,  or  ephemeral;  each  of  which  corresponds 
to  a  peculiar  type  of  the  pathologic  process.  Park  has  suggested  a  division  into : 
(i)  chronic,  (2)  fibroid,  (3)  septic  infectious  (pyogenic),  (4)  mixed  form. 

I  have  described  three  groups,f  in  which  I  include  the  painful  form  under 
the  head  of  the  chronic  ulcerative  type,  as  follows : 

1.  Acute  tubercular  form.     (Miliary.) 

2.  Chronic  ulcerative  form.     (Pyogenic  miliary.) 

3.  Chronic  tubercular  form.     (Fibroid.) 

This  division  corresponds  with  the  manifestation  of  tuberculosis  in  the 
lungs,  the  acute  miliary,  the  chronic  ulcerative,  and  the  fibroid  phthisis. 

These  three  groups  may  be  described  as  follows: 

I.  The  acute  tubercular  form.  This  type  of  hip  disease  is  the  analogue 
of  acute  pneumonic  tuberculosis,  commonly  known  as  galloping  consumption. 
It  occurs  in  both  children  and  young  adults  with  inherited  tendency  and  slight 
resistance.    Two  types  may  be  recognized — a  synovial  and  an  osteitic. 

(c)  In  the  synovial  variety  the  onset  is  abrupt  and  acute,  and  usually 
in  an  individual  who  has  previously  enjoyed  good  health,  although  in  many 
cases  there  may  be  a  history  of  exposure  to  cold,  or  of  traumatism.  If  the 
fungous  granulations  are  scanty,  there  is  copious  effusion,  tuberculous  hydrops, 
marked  fluctuation,  slight  deformity,  severe  pain,  and  normal  temperature. 
The  condition  may  terminate  at  this  stage  or  may  become  a  fungous  synovitis. 

"If  granulation  tissue  be  abundant,  there  is  little  or  no  effusion  in  the  joint, 
slight  or  no  fluctuation,  extensive  deformity,  without  much  suffering,  and  with 
slight  fluctuations  of  temperature  from  the  normal.  Suppuration  may  occur 
in  the  granulations,  and  pus  may  accumulate  in  the  joint  until  the  capsule 
is  ruptured  and  general  infection  occurs,  or  a  spontaneous  or  artificial  opening 

*  "  Boston  Med.  and  Surg.  Jour.,"  April  13,  1S92.  f  "  Med.  News,"  April  15,  1S93. 


HIP-JOINT  DISEASE.  311 

exposes  the  individual  to  infection  with  pus-microbes  from  without,  with  rapid 
impairment  of  the  general  condition,  pyrexia,  hectic  and  progressive  anemia, 
and  emaciation. 

"  (&)  In  the  osteitic  variety  the  commencement  is  likewise  sudden  in  persons 
debilitated  from  acute  infectious  diseases,  or  from  any  cause.  Pain  initiates 
the  attack,  and  is  a  prominent  symptom  throughout  the  disease.  Localized 
tenderness  on  pressure  is  early  present,  and  is  one  of  the  most  positive  indica- 
tions of  osteo-tuberculosis.  There  is  little  swelling  or  edema,  until  the  para- 
periosteal  structures  become  infected.  Then  the  para-articular  tissues  become 
markedly  indurated,  and  abscess  formation  rapidly  occurs.  Muscular  spasm, 
deformity,  and  atrophy  are  extreme.  The  pyrexia  runs  high,  and  the  general 
condition  rapidly  deteriorates.  This  destruction  is  rapid  and  death  may  occur 
from  exhaustion,  tubercular  meningitis,  or,  if  the  disease  drags  on  into  the 
chronic  ulcerative  form,  from  amyloid  degeneration. 

"While  the  disease  is  confined  to  the  articular  structures  it  is  a  pure,  florid, 
rapid  tuberculosis;  but  when  ruptured  abscesses  and  sinuses  expose  an 
exquisitely  prepared  tissue-soil  to  atmosphere  infection,  suppurative  microbes 
inaugurate  a  local  septic  process,  and  finally  a  pyemia. 

"2.  The  chronic  ulcerative  form.  Under  this  heading  may  be  grouped 
the  great  majority  of  cases  of  hip-tuberculosis  in  which  the  lesions  proceed 
to  ulceration  and  softening,  and  ultimately  produce  the  well-known  picture 
of  chronic  hip  disease. 

"A  purely  tuberculous  affection  from  the  first,  it  ultimately  becomes  in 
many  cases  a  mixed  disease,  many  of  the  most  prominent  symptoms  of  which 
are  due  to  purulent  cavities  and  septic  infections." 

The  general  description  which  follows  in  this  work  represents  this  type 
of  hip  disease,  the  chronic  ulcerative  form. 

"3.  The  chronic  tubercular  form.  This  group  includes  a  class  of  cases 
which  while  not  common  are  sufficiently  numerous  to  form  a  well-recognized 
t3rpe.  The  onset  is  gradual  and  the  progress  of  the  disease  slow.  Muscular 
spasm  is  an  early  and  constant  symptom,  fixing  the  limb  rigidly  in  the  majority 
of  instances.  In  a  few,  particularly  when  there  has  been  much  shortening, 
there  may  be  great  mobility  without  pain. 

The  local  sensibility  is  not  increased  and  pain  as  an  important  symptom 
is  absent.  Night  cries  may  be  present,  but  are  insignificant.  Muscular 
atrophy  and  shortening  are  the  prominent  characteristics.  Abscesses  seldom 
occur,  but  when  present  are  accompanied  by  extreme  shortening  of  the  limb, 


312  ORTHOPEDIC  SURGERY. 

and  in  some  instances  entire  destruction  of  the  head  of  the  femur.  The  tendency 
is  toward  recovery,  with  great  shortening,  extreme  atrophy,  and  firm,  fibrous 
ankylosis.  The  condition  is  one  of  sclerosis  and  induration  with  gradual  shrink- 
age, from  the  superabundance  of  fibrous  tissue,  the  tendency  of  the  pathologic 
process  being  conservative  and  healing." 

Stage  of  Onset. — The  symptoms  indicating  the  onset  of  the  disease  are 
very  insidious,  and  consist  of  lameness,  pain,  induration  about  the  joint, 
limitation  of  motion,  muscular  atrophy,  glandular  engorgement  in  the  neighbor- 
hood of  the  joint,  together  with  slight  constitutional  derangement. 

Lameness.  Among  the  earliest  signs  which  denote  this  disease  in  its 
incipiency  is  a  slight  limp  observed  in  the  gait  of  the  child.  This  may  be 
noticeable  in  the  morning  on  rising  from  bed,  and  generally  passes  away  in 
a  short  time.  It  is  more  marked  after  a  previous  day  of  great  activity.  But, 
as  a  rule,  the  limp  occurs  later  in  the  day,  in  this  manner  differing  from  spine 
disease,  in  which  the  pain  and  stiffness  are  most  marked  in  the  early  morning 
on  arising.  This  limp  is  partially  due  to  a  stiilness  about  the  joint,  and  to  the 
pain  which  is  also  present  at  this  time,  and  is  aggravated  by  motion,  though 
it  may  be  absent  in  any  or  all  of  the  stages  of  the  disease. 

Pain.  Accompanying  this  limp  pain  is  an  early  and  frequent  s}'mptom, 
and  is  usually  referred  to  the  knee.  It  is  usually  periodic,  evanescent,  appearing 
suddenly  while  the  child  is  at  play,  or  coming  on  in  the  latter  part  of  the  day, 
and  disappearing  during  the  night.  This  pain  in  the  knee  has  been  variously 
explained.  It  has  been  ascribed  to  the  pressure  of  the  internal  lateral  ligament 
against  the  condyle  of  the  femur,  induced  by  the  malposition  of  the  limb.  It 
is  now,  however,  generally  considered  to  be  reflex,  induced  by  pressure  on  the 
obturator  nerve,  transmitted  to  the  short  saphenous  nerve,  through  the  communi- 
cating branch,  which  passes  between  the  femoral  and  profunda  femoris  vessels. 
Other  explanations  have  been  offered  to  explain  this  reflected  pain.  The 
pain  is  experienced  upon  the  anterior  and  internal  lateral  surface  of  the  joint 
over  a  considerable  area,  usually  about  the  size  of  the  patient's  hand,  differing 
in  this  respect  from  the  localized  pain  in  knee-joint  disease,  the  area  of  which 
is  small. 

Induration.  The  marked  swelling  about  the  trochanter  ■\\'hich  is  so 
characteristic  of  the  later  stages,  is  but  slightly  marked  at  this  period.  There 
is,  however,  if  the  trochanter  be  deeply  and  firmly  grasped,  some  enlargement 
and  hardening  of  the  joint  apparent;  particularly  is  this  marked  if  the  disease 
is  pelvic  in  its  origin. 


HIP-JOINT  DISEASE.  ,  313 

Limitation  of  motion.  A  state  of  spasm  or  muscular  rigidity  of  the 
joint  is  among  the  first  and  most  important  symptoms  of  this  disease.  This 
is  one  of  the  earliest  signs  always  present;  it  is  very  persistent,  and  is  the  result 
of  reflex  muscular  spasm,  accompanied  by  an  unconscious  automatic  contraction 
of  the  muscles  to  fix  the  joint  and  diminish  the  jar  in  walking.  This  muscular 
rigidity,  together  with  the  atrophy  which  it  induces,  are  the  two  most  positive 
symptoms  of  hip  disease  at  this  stage.  The  limb  is  held  in  a  position  of  slight 
flexion,  and  in  some  cases  slight  abduction.  This  constant  tetanic  contraction 
not  only  produces  the  malposition  of  the  limb  referred  to,  but  by  forcing  the 
head  of  the  bone  against  the  acetabulum  produces  a  destruction  of  the  cartUage 
and  an  increase  of  pain.  Associated  with  this  rigidity  about  the  hip-joint 
there  is,  often,  also  a  muscular  irritability  of  the  lower  erector  spinae  muscles 
and  the  muscles  adjacent  to  the  joint.  This  muscular  rigidity  about  the  joint, 
when  slight,  may  be  noticeable  only  when  extreme  flexion  and  extension  are 
made,  the  range  of  motion  in  the  middle  of  flexion  being  slightly  or  not  at  all 
impaired.  Anesthesia  reveals  the  true  nature  of  this  rigidity,  the  muscular 
spasm  entirely  disappearing  if  no  adhesion  or  muscular  contracture  exist. 

Atrophy.  Wasting  of  the  muscles  of  the  thighs  and  buttocks  is 
characteristic  of  the  disease.  It  occurs  early  and  persists  throughout  the  course 
of  the  affection.  That  this  is  not  the  atrophy  of  disuse  is  shown  by  the  fact 
that  it  occurs  so  early  and  advances  so  rapidly.  Paget  designated  it  reflex 
atrophy,  but  Brown-Sequard's  experiments  led  him  to  believe  that  the  wasting 
is  due  to  an  irritation  of  the  nerves,  independent  of  the  trophic  centers.  That 
the  trophic  centers  are,  however,  affected  would  seem  to  be  proved  by  the  fact 
that  not  only  do  the  soft  parts  waste,  but  the  bone  also  becomes  diminished, 
both  in  diameter  and  length. 

According  to  Charcot  and  Vulpian,  as  the  effect  of  the  tetanoid  spasm 
there  occurs  a  change  or  "inertia"  of  the  trophic  centers  of  the  spinal  cord, 
while  Saborin  has  suggested  a  molecular  neuritis  from  direct  involvement  of 
the  nerve  filaments.  The  increased  use  of  the  sound  limb  also  causes  a  relative 
hypertrophy  which  exaggerates  the  atrophy  of  the  affected  part. 

In  hip  disease  the  atrophy  is  found  to  be  greater  as  a  result  of  fixation 
in  the  treatment  of  the  condition.  This  was  shown  in  the  observations  of  Dr. 
Brackett,  who  in  two  groups  of  cases,  in  one  of  which  fixation  was  employed 
and  in  the  other  of  which  free  motion  was  permitted,  found  that  the  atrophy 
was  much  greater  in  the  former  group,  amounting  to  23  per  cent,  of  the  volume 
of  the  thigh  and  17  per  cent,  of  that  of  the  leg,  as  compared  with  i  per  cent. 


314  ^       ORTHOPEDIC  SURGERY. 

of  the  volume  of  the  thigh  and  0.89  per  cent,  of  that  of  the  leg.  A  certain  amount 
of  this  atrophy  is  due  to  disuse,  and  also  results  from  lack  of  function,  the  natural 
stimulus  of  the  part. 

The  amount  of  atrophy  is  best  estimated  by  circumferential  measurements 
taken  about  the  thigh,  at  points  equidistant  from  the  internal  condyle,  upon 
the  affected  and  sound  limb.  In  this  manner  the  slightest  degree  of  atrophy 
can  be  estimated,  and  will  be  found  present  in  some  cases  even  before  the  advent 
of  pain.  Similar  measurements  of  the  circumference  of  the  calf,  on  either 
side,  will  demonstrate  the  absence  of  atrophy  in  them  at  this  early  period.  This 
atrophy  differs  from  the  wasting  of  paralysis,  in  that  the  muscles  retain  their 
firmness  or  are  unusually  hard. 

Glandular  engorgement.  Though  the  inguinal  glands  are  frequently 
enlarged  in  patients  of  a  strumous  diathesis,  the  enlargement  of  the  deep  glands 
above  Poupart's  ligament  is  a  frequent  and  early  sign  of  this  affection.  Deep 
pressure  in  this  situation  reveals  their  presence,  and  palpation  is  painful.  Atten- 
tion has  been  particularly  called  to  this  by  Lannelongue  and  other  French 
writers,  who  have  noted  their  presence  even  in  the  early  months.  The  swelling 
of  these  inguinal  glands  is  thought  by  some  to  indicate  osteitis,  but  others  believe 
they  often  indicate  disease  of  the  pelvis  rather  than  of  the  femur.  Their  suppura- 
tion usually  indicates  pelvic  disease. 

General  condition.  The  constitution  at  this  early  stage  suffers  but 
little,  and  in  many  cases  the  physical  appearance  but  little  indicates  the  grave 
pathologic  process  going  on  within.  The  appetite  may  be  diminished,  the 
digestion  enfeebled,  and  the  disposition  irritable,  but  in  the  majority  of  cases 
the  premonitory  stage,  if  any,  passes  unobserved.  In  many  of  these  children 
a  large  but  unnatural  accumulation  of  adipose  tissue  produces  an  impression 
of  health  which  really  does  not  exist.  The  deposit  of  fat  may  be  greater  on 
the  affected  side,  and  English  writers  have  referred  to  this  unequal  distribution 
as  a  diagnostic  sign. 

Stage  of  Apparent  Lengthening. — The  second  stage  is  marked  by  an 
increase  of  all  these  symptoms,  and  the  advent  of  three  other  signs:  "night- 
cries,"  suppuration,  and  grating,  or  joint  crepitation. 

Lameness.  The  slight  limp  referred  to  in  the  first  stage  is  in  the  second 
stage  a  decided  lameness,  being  due  to  the  altered  position  of  the  limb  in  flexion, 
tilting  of  the  pelvis  and  apparent  elongation  of  the  limb,  or  to  actual  shortening. 
In  standing  at  rest  the  body-weight  is  transferred  to  the  sound  limb,  and  the 
aft"ected  limb  is  advanced  and  rested  as  much  as  possible. 


HIP-JOINT  DISEASE.  315 

Pain.  The  pain  referred  to  the  knee  increases  in  intensity  and  duration, 
and  to  this  is  added  pain  in  walking  and  upon  motion.  It  is  relieved  by  gentle 
traction  on  the  line  of  deformity.  So  great  may  the  sensitiveness  of  the  joint 
become  that  the  slightest  motion  or  jarring  causes  excruciating  agony.  The 
pain  is  increased  by  forcing  the  joint  surfaces  together,  but  this  is  cruel  and 
entirely  unwarranted,  since  it  adds  nothing  of  diagnostic  value.  The  location 
of  the  pain  remains  the  same,  and  attempts  to  differentiate  the  locality  of  the 
bone  lesion  are  unsatisfactory.  Erichsen  has  suggested  that  a  pain  in  the 
knee  indicated  "femoral  coxalgia";  pain  in  the  joint,  "arthritic  coxalgia," 
and  pain  in  the  iliac  fossa,  or  side  of  the  pelvis,  "acetabular  coxalgia."  The 
pain  increases  with  the  distention  of  the  capsule,  and  during  the  exacerbation 
of  the  disease,  and  usually  ceases  abruptly  with  the  rupture  of  the  capsule 
and  the  extravasation  of  the  pus  into  the  surrounding  tissue.  Though  an 
early  and  persistent  sign  of  the  disease,  pain  may  be  entirely  absent  in  any 
or  all  of  its  stages,  so  that  as  an  individual  diagnostic  sign  it  is  of  little  value. 

Induration.  Thickening  and  hardening  about  the  trochanter  is  indicative 
of  suppuration  within  the  joint,  and  Wright  considers  it  pathognomonic  of  it. 
It  is  therefore  particularly  characteristic  of  this  stage.  It  is  best  recognized 
by  grasping  the  trochanters  with  each  hand,  the  thumbs  in  front  and  the  fingers 
applied  well  down  into  the  post-trochanteric  fossa.  In  this  manner  the  two 
sides  can  be  carefully  compared. 

Limitation  of  motion.  The  position  of  the  thigh  is  changed  by  the 
muscular  spasm  and  the  formation  and  accumulation  of  pus  within  the  joint. 
The  thigh  is  flexed,  abducted,  and  rotated  outward,  the  position  having  been 
demonstrated  by  experiments  to  be  the  one  in  which  the  capacity  of  the  joint 
is  greatest.  The  coxo-femoral  joint  is  more  or  less  fixed,  and  if  the  pelvis  retains 
its  normal  position  the  flexed,  abducted,  and  rotated  position  of  the  limb  is 
not  only  unsightly,  but  unfavorable  to  progression.  To  overcome  this  flexion 
the  pelvis  is  tilted  downward;  to  overcome  the  abduction,  which  is  essentially 
an  unfavorable  position  for  walking,  the  pelvis  is  tilted  laterally;  to  overcome 
the  rotation  of  the  head  of  the  bone,  the  pelvis  is  tilted  on  its  axis  toward  the 
sound  side,  so  as  to  render  the  anterior  superior  spinous  process  prominent 
and  removed  far  from  the  axis  of  the  trunk. 

This  alteration  in  the  position  of  the  pelvis  is  reflex  in  nature,  and  occurs 
consecutively  with  the  osseous  changes.  That  it  is  muscular  and  reflex  is 
demonstrated  by  the  fact  that  under  profound  anesthesia  the  fixation  disappears 
and  the  limb  may  be  placed  and  examined  in  a  normal  position.     Later,  how- 


316  ORTHOPEDIC  SURGERY. 

ever,  after  the  contraction  has  existed  for  soine  time,  this  simple  muscular 
contraction  is  succeeded  by  structural  alterations  of  the  muscles,  capsule,  bones, 
etc.,  which  render  the  position  of  the  limb  more  or  less  permanent. 

The  amount  of  deformity  present  can  be  ascertained  by  the  employment  of 
special  instruments,  as  the  compass  of  Martin  and  Collineau,  the  ingenious 
goniometer  of  Roberts,  or  they  may  be  deduced  with  mathematic  precision 
by  the  geometric  procedures  of  Giraud-Teulon,  and  the  elaborate  tables  of 
Bradford  and  Lovett.  The  simplest  method  and  the  one  most  generally 
employed  consists  in  placing  the  recumbent  body  in  such  a  position  that  the 
anterior-superior  spinous  processes  are  on  a  horizontal  line,  and  measuring 
from  these  on  either  side  to  the  internal  malleolus  on  the  corresponding  side. 
By  this  means  the  real  or  bony  shortening  may  be  ascertained.  If  the  amount 
of  practical  shortening  be  desired,  measurement  must  be  made  from  the  umbilicus 
to  each  malleolus,  and  by  comparing  these — the  real  or  bony  shortening  and 
the  practical  shortening — the  degree  of  adduction  and  abduction  may  be  obtained. 
This  will  be  referred  to  again  in  speaking  of  diagnosis. 

Atrophy.  The  wasting  of  the  muscles  progresses  during  the  second  stage, 
and  to  the  atrophy  from  the  tetanoid  spasm,  always  present,  is  added  an  amount 
of  atrophy  from  disuse  commensurate  with  the  severity  of  the  disease  and  the 
inability  to  use  the  leg.  In  this  manner  atrophy  of  the  calf  and  other  muscles 
not  affected  during  the  first  stage  is  added  and  contributes  a  new  symptom 
to  distinguish  this  stage  from  the  first. 

Flattening  of  the  buttock.  The  abduction  and  flexion  of  the  thigh 
and  the  atrophy  of  the  gluteal  muscles  upon  the  affected  side  lead  to  flattening 
of  the  buttock  and  obliteration  of  the  fold  of  the  nates  upon  this  side.  This 
gluteal  atrophy,  like  the  adductor  atrophy  before  referred  to,  is  reflex  and 
characteristic  of  the  disease;  the  muscles,  though  wasted,  are  hard  and  tense, 
and  not  soft  and  flabby.  Periarticular  swelling  also  plays  a  part  in  the 
obliteration  of  the  fold  of  the  nates. 

Night-cries.  Though  "night-cries,"  or  night-shoutings,  may  occur 
early  in  the  disease,  they  are  significant  of  this  stage.  They  occur  early  in 
the  night,  and  some  patients  lie  awake  as  long  as  possible,  fearful  of  their  advent. 
As  the  child  is  losing  consciousness,  the  muscular  relaxation  accompanying 
this  stage  allows  pressure  or  friction  of  the  tender  surfaces  within  the  joint, 
causes  acute  pain,  a  sudden  awakening  with  a  loud  cry,  and  a  violent  spasm 
of  the  muscles  to  again  fix  the  joint.  After  moaning  and  crying  for  some  time 
sleep  is  again  attempted,  with,  perhaps,  a  renewal  of  these  disagreeable  symptoms. 


HIP-JOINT  DISEASE.  317 

This  may  be  repeated  several  times  during  the  night,  and  indicates  extension 
or  an  exacerbation  of  the  disease.  They  resemble  somewhat,  but  should  not 
be  confounded  with,  nightmare,  or  "night  terrors,"  from  which  the  severe  pain 
and  the  absence  of  disagreeable  dreams  serve  to  distinguish  them.  The  condi- 
tion is  described  by  patients  old  enough  to  distinguish  symptoms,  as  extremely 
sudden  and  severe  pain,  followed  by  an  aching  or  bruised  sensation  in  the  thigh 
and  hip. 

Abscess.  Hip  disease  may  run  its  entire  course  without  suppurating, 
either  extra-articular  or  intra-articular,  the  process  being  a  caries  sicca,  a  non- 
suppurative osteitis,  which  has  already  been  described  as  the  chronic  tuberculous 
form;  but,  as  a  rule,  abscesses  are  a  frequent  and  serious  complication.  The 
presence  of  pus  indicates  the  destructive  character  of  the  osteitis,  though 
extensive  collections  may  spontaneously  undergo  caseation  and  absorption 
without  much  destruction  of  tissue,  a  "residual  abscess"  resulting.  They 
occur  but  rarely  during  the  onset,  but  may  be  the  first  symptom  to  attract 
the  attention  of  the  parent  or  the  patient  to  the  affected  part.  They  are 
characteristic  of  this  period,  and  occur  from  the  sixth  to  the  fifteenth  month, 
though  they  may  be  much  later.  According  to  Lovett  and  Goldthwait,*  of  all 
the  (sixty-three)  cases  examined  with  reference  to  this  subject,  abscess  occurred 
within  one  year  in  59  per  cent.,  within  two  years  in  13  per  cent.,  in  three  to  five 
years  in  nine  cases,  and  in  the  seventh  and  ninth  year  one  each.  The  frequency 
appears  to  be  directly  influenced  by  the  efficiency  of  appropriate  treatment,  and 
the  stage  during  which  it  is  begun.  Thus,  the  percentage  of  abscesses  occurring 
in  the  series  of  cases  collected  by  Gibney,  Marsh,  the  Clinical  Society's  Com- 
mittee, and  Lovett  and  Goldthwait,  is  from  23  to  69  per  cent.,  of  which  from 
41  to  50  per  cent,  developed  before  the  patients  came  under  treatment. 

The  origin  and  course  of  the  abscess  will  depend  upon  the  location  and 
extent  of  the  tuberculous  focus.  From  an  epiphyseal  osteitis  the  pus  may  extend 
in  a  course  outside  of  the  joint  and  become  extra- articular ;  so,  also,  an  extra- 
articular abscess  may  invade  the  joint.  Suppuration  in  hip-joint  disease 
coincides,  in  general  features,  with  cold  abscesses  from  osteitis  elsewhere.  The 
advent  is  usually  without  constitutional  disturbance,  but  slight  evening  rise 
of  temperature,  slight  rigors,  and  perspiration  may  mark  its  progress.  The 
complexion  is  pallid  from  the  increased  number  of  white  blood-corpuscles 
in    the    blood, — suppurative    leukocythemia, — the    appetite  is  capricious,  but 

*  "  Trans.  Amer.  Orthop.  Assoc,"  vol.  ii,  p.  86. 


318  ORTHOPEDIC  SURGERY. 

otherwise  the  general  condition  may  be  but  little  affected.  Locally,  the  abscesses 
follow  the  fascias,  and  seek  exit  in  the  direction  of  least  resistance,  opening 
at  some  distance  from  the  seat  of  disease,  accumulating,  in  some  instances, 
until  they  assume  enormous  proportions,  or  burrowing  to  great  distances. 
The  abscesses  may  open  in  many  places;  the  author  has  counted  fifteen;  in 
the  case  of  Lund  there  were  no  less  than  twenty-one  different  openings.  The 
course  and  exit  depend  upon  the  location  of  the  original  disease,  and  attempts 
have  been  made  to  classify  the  different  routes  followed  by  the  suppuration, 
and  utilize  the  knowledge  for  diagnostic  purposes.  While  the  pointing  is 
significant,  it  is  not  a  positive  indication. 

In  the  321  abscesses  reported  by  Konig  occurring  in  hip-joint  disease 
the  exit  was  as  follows: 

On  the  inner  side  (inside  the  femoral  artery) 26 

Front  of  the  joint  (between  artery  and  anterior  superior  spine), 126 

Region  of  the  trochanter, 63 

Posterior  surface, 49 

In  the  pehis, 41 

In  other  situations, 16 

Three  varieties  of  abscesses  may^  be  distinguished,  based  upon  the  primary 
lesion:  Arthritic,  femoral,  and  acetabular.  Suppuration  occurs  earlier  in 
the  acetabular  than  in  the  femoral  variety. 

In  the  arthritic  variety,  if  the  head  of  the  femur  does  not  press  specially 
upon  any  part  of  the  capsule,  the  pus  will  find  exit  at  the  inner  side,  and  point 
at  the  inner  side  of  the  thigh  among  the  adductors.  If  the  limb  be  adducted 
and  rotated  outward,  the  head  of  the  femur  presses  against  the  anterior  part 
of  the  capsule,  the  weakest  spot  at  the  capsule,  and  gives  way  at  that  point. 
In  this  event  the  pus  enters  the  sheath  of  the  psoas  and  iliacus,  simulating 
a  psoas  abscess,  or  burrows  downward  toward  the  inner  side  of  the  thigh.  If 
the  limb  be  adducted  and  rotated  inward,  the  pus  escapes  at  the  posterior  part 
of  the  capsule — another  weak  point — to  enter  the  pelvis  along  the  course  of  the 
external  rotators,  or,  what  is  more  common,  points  below  the  gluteus  maximus. 

In  the  femoral  variety  they  open  directly  into  the  joint,  to  terminate 
eventually  as  the  arthritic  abscess  before  given,  or,  escaping  from  the  bone, 
open  upon  the  outer  or  anterior  aspect  of  the  thigh.  An  abscess  opening  upon 
the  outer  part  of  the  thigh,  below  the  trochanter,  indicates  disease  of  the  caput 
femoris,  and  abscesses  which  burst  below  and  in  front  of  the  great  trochanter 
are  indicative  of  disease  of  the  femur. 

In  the  acetabular  variety,  owing  to  the  peculiar  anatomic  relations,  purulent 


HIP-JOINT  DISEASE. 


319 


collections  vary  much  in  their  course  and  exit.  They  may  burst  through  the 
capsule  and  point  in  the  inguinal  region,  or,  perforating  the  pelvis,  may  pursue 
a  circuitous  route  before  being  eventually  discharged.  Abscesses  opening 
in  the  pubic  region  denote  disease  of  the  acetabulum — the  abscess  being  intra- 
pelvic  or  extra-pelvic,  according  as  it  opens  above  or  below  Poupart's  ligament. 
A  pubic  abscess  pointing  above  Poupart's  ligament  is  usually  due  to 
pelvic  disease  on  its  inner  aspect  or  to  perforation  of  the  acetabulum.  Wright 
concludes  that  v^^hen  an  abscess  points  on  the  front  of  the  limb  above  a  line 
dravi^n  through  the  upper  border  of  the  great  trochanter,  there  is  disease  of  the 
pelvis,  and  this  is  the  more  certain,  the  higher  and  the  more  internal  the 
opening. 

In  the  acetabular  variety,  in  pelvic  accumulations  from  perforations  of 
the  acetabulum,  the  pus  (i)  traverses  the  internal  obturator  muscle  to  become 
a  gluteal  abscess;  (2)  fills  the  internal  Uiac  fossa,  and  becomes  a  pubic  abscess; 
(3)  burrows  through  the  external  obturator  muscle  to  become  an  internal  crural 
abscess,  or  (4)  opens  internally,  traversing  the  obturator  internal  muscle  to 
open  into  the  peritoneal  cavity,  the  rectum,  urethra,  bladder,  vagina,  and  upon 
the  skin  at  the  margin  of  the  anus.  Abscess  pointing  between  the  scrotum 
or  labium  and  the  thigh  is  always  of  serious  import,  indicating  pelvic  disease. 
Gluteal  abscesses  may  be  due  to  disease  of  either  the  femur  or  acetabulum. 


ORIGINAL  TABLE  OF  ABSCESSES. 


Variety. 

Course. 

Exit. 

r 

a. 

Through  inner  side  of  capsule. 

Inner  side  of  thigh  among  adductors. 

b. 

Through  anterior  and  inner  side  of  capsule. 

Enters  sheath  of  psoas  and  iliacus,  and 

I.  Arthritic ■ 

burrows  to  inner  side  of  thigh. 

c. 

Through  posterior  part  of  capsule. 

Along  course  of  external  rotators  or 
below  gluteus  maximus. 

a. 

Directly  into  joint. 

As  in  arthritic  variety,  upon  outer  or 

2.  Femoral ■ 

b. 

Outer  or  anterior  course. 

anterior  aspect  of  thigh  below  the 
trochanter. 

a. 

Through  anterior  part  of  capsule. 

In  inguinal  region  below  Poupart's 
ligament. 

b. 

Perforates  acetabulum: 

3.  Acetabular  . . 

I.  Through  internal  obturator  muscle. 

As  gluteal  abscess. 

2.  Fills  internal  iliac  fossa. 

As  pubic  abscess. 

3.  Perforates  external  obturator  muscle. 

As  internal  crural  abscess. 

4.  Into  peritoneal  cavity. 

Into  rectum,  urethra,  bladder,  vagina, 
and  at  verge  of  anus. 

Though  possible,  it  is  rare  for  purulent  accumulations  to  be  absorbed 
after  they  have  acquired  a  certain  volume.  When  the  pus  reaches  the  surface, 
it  appears  as  a  tense  fluctuating  swelling,  of  uniform  color,  with  prominent 


320  ORTHOPEDIC  SURGERY. 

superficial  veins.  Wlien  pointing  occurs,  the  skin  becomes  red,  thin,  and 
ulcerates  in  one  or  more  places.  These,  if  small,  readily  heal  after  the  exit 
of  the  pus;  they  break  down  into  large  tuberculous  ulcers,  or  remain  indefinitely 
as  orifices  of  sinuses  or  fistulas  filled  with  exuberant  granulations.  These 
fistulas  afford  some  clue  to  the  seat  of  the  disease,  but  cannot  be  readOy  explored 
on  account  of  the  tortuosity  of  their  course.  Fistulas,  originally  pelvic,  are 
distinguished  by  bearing-down  efforts  of  the  patient,  causing  the  escape  of 
purulent  Hquid. 

As  long  as  the  bone  disease  is  active  the  sinuses  continue  to  discharge, 
and  any  attempt  at  their  closure  is  followed  by  marked  constitutional  symptoms — 
headache,  anorexia,  pyrexia,  and  anemia.  The  sinuses  may  continue  long 
after  the  local  disease  is  healed,  but  the  discharge  will  not  be  abundant. 

Grating,  or  joint  crepitation.  From  erosion  of  cartilage  and  exposure 
of  the  cancellous  structure  of  the  joint  surfaces,  grating,  or  joint  crepitation 
from  friction,  may  occasionally  in  severe  cases  be  elicited.  Great  care  must 
be  exercised  lest  injury  result  from  rough  manipulation.  This  may  be  obscured, 
even  where  considerable  destruction  exists,  by  the  presence  of  abundant  granula- 
tions, or  where  but  one  point  of  the  bone  is  denuded,  or  where  two  or  more 
roughened  surfaces  exist  but  do  not  approximate. 

General  condition.  In  the  second  stage  children  suffering  from  this 
affection  are  often  apparently  robust,  especially  in  the  intervals  between  the 
exacerbations  which  characterize  the  affection.  When,  however,  abscess 
occurs,  and  especially  when  suppuration  is  profuse  from  the  sinuses,  anorexia, 
pallor  of  the  skin,  fluctuations  of  temperature,  irritability,  and  diarrhea  mark 
the  progress  of  the  disease. 

Stage  of  Real  Shortening. — The  third  stage  is  characterized  by  the 
adduction,  shortening,  dislocation,  or  ankylosis  of  the  joint,  ending  in  recovery; 
or  suppuration,  destruction  of  the  joint,  adynamic  symptoms,  and  death  from 
some  visceral  lesion. 

Pain.  The  "starting"  pains  and  night-cries  are,  in  the  third  stage,  at 
times  gradually,  sometimes  suddenly,  relieved.  A  feeling  of  tension  and  tender- 
ness remains,  and  may  increase  from  the  accumulation  of  pus.  When  the 
disease  is  very  extensive,  marked  swelling  occurs  from  edema  of  all  the  periar- 
ticular structures. 

Dislocation  is  often  attended  with  considerable  abatement  of  pain — some 
times  complete  and  permanent,  sometimes  transitory.  Dislocation,  particularly 
subluxation,  is  often  attended  with  sudden  and  severe  pain.     The  character 


HIP- JOINT  DISEASE. 


321 


of  the  ordinary  pain  in  this  stage  is  not  available  to  distinguish  the  form  of 
the  original  disease. 

Temperature.  Patients  suffering  from  hip  disease  have,  as  a  rule, 
throughout  the  disease  an  evening  elevation  of  one  or  two  degrees  above  normal. 
When  attacked  by  some  intercurrent  affection  of  childhood  the  temperature 
may  be  found  one  or  two  degrees  above  that  of  others  affected  by  the  same 
disease.  A  sudden  rise  of  temperature  to  103°  or  over  during  the  early  stages 
is  not  so  likely  to  indicate  abscess  forma- 
tion as  a  great  range  of  daily  tempera- 
ture. Continued  high  fever  or  great 
ranges  of  temperature  in  the  later  stages 
of  the  disease  would  be  significant  of  in- 
fection of  the  tuberculous  Collection  by 
pyogenic  germs. 


Fig.   292. — Masked  Ateophy  and  Deformity   in 
Advanced  Hip-joint  Disease. 


Fig.  293. — Extreme  Atrophy  following  Hip- 
joint  Disease. 


Limitation  of  motion.  Adduction,  flexion,  and  shortening  characterize 
the  position  of  the  thigh  in  this  stage.  This  change  from  abduction  and  apparent 
elongation  of  the  second  stage  into  adduction  and  shortening  of  the  third  stage 
may  occur  rapidly,  the  position  of  months  or  years  being  reversed  in  a  day. 

Capsular  contraction  and  muscular  spasm  are  probably  the  cause  of  the 
adduction,  while  the  elevation  and  backward  thrusting  of  the  pelvis  and  muscular 
spasm  account  for  the  early  shortening.     Later,   actual  osseous  destruction 


322 


ORTHOPEDIC  SURGERY. 


and  dislocation  of  the  head  of  the  femur  are  the  true  explanation  of  the  real 
shortening  observed. 

Shortening.  The  actual  shortening  which  occurs  from  destruction 
of  the  bones,  with  the  addition  of  atrophy  from  disuse,  amounts  in  time  to  a 
considerable  real  shortening.  This  is  well  shown  in  the  following  table  from 
Bollinger:* 


Age  of  Inception.  1 


Years.       Months,  i     Years.       Months.  '    Diseased.      Normal. 


2, 3 

3. 2 

4, S 

5, 6 

.6, 7 

7. 9 

8, ;  I 

9. i  13 

10 4 

II, 

12, 13 

13. 2 

14, I  6 

15. " 

16, I  5 

17. 5 

18 6 

19, ,  2 


28J 


Diseased.  I    Nonnal. 


36 

44i 


24 

19 

19-5 

23-5 

23 

27 

3° 

18.5 

34 

27 

2ii 

23, 

28 

31 
34 
34 
31 
36 
3S 
37-5 


24 

19 

19-5 

23-5 

23 

27 

3° 
19 
34 
27 
23 
33 
28 

32 

34 

34 

37 

39-S 

38 

37-5 


Occasionally  where  the  disease  has  not  progressed  far  real  lengthening  may 
occur  in  the  diseased  side,  being  partially  due  to  traction,  and  to  the  stimulated 
growth  through  irritation  of  the  epiphysis.  After  the  disease  is  arrested  the 
growth  may  continue,  but  does  not  keep  pace  with  the  sound  limb,  and  the 
relative  difference  in  the  limbs  increases,  as  was  showoi  in  a  series  of  cases  examined 
by  Shaffer  and  Lovett.f 

Though  frequently  described  in  systematic  treatises,  it  is  probable  that 
true  dislocation  from  hip-joint  disease  very  rarely  occurs. 

In  destruction  of  the  head  of  the  femur,  erosion  of  the  brim  of  the 
acetabulum,  in  the  so-called  "traveling  acetabulum,"  perforation  of  the 
acetabulum  by  the  head  of  the  femur,  or  where  the  trochanter  is  pushed  upward, 
the  head  remaining  in  the  acetabulum,  dislocation  cannot  be  said  to  have 
occurred.  True  instances  of  dislocation  are  chiefly  confined  to  the  femoral 
variety,  and  if,  as  sometimes  happens,  it  occurs  without  suppuration,  from  the 


"Zeits.  f.  orth.  Chir.,"  1S92,  Bd.  i. 


t  "N.  Y.Med.  Jour.,"  May  21,  1887. 


HIP-JOINT  DISEASE.  323 

formation  of  a  "fungous  fibro-plastic  mass"  in  the  acetabulum,  or  where, 
by  mere  distention  of  the  capsule,  with  rupture  of  the  ligamentum  teres,  a  new 
socket  may  be  developed  upon  the  dorsum  ilii  or  within  the  obturator  foramen. 
With  the  adduction  and  shortening  there  are  associated  undue  prominence 
of  the  buttock  on  the  affected  side,  marked  upward  and  backward  obliquity 
of  the  pelvis,  lordosis,  and  a  compensatory  double  lateral  curvature  of  the  spine. 
The  lordosis  is  the  result  of  fixation  or  ankylosis  of  the  thigh  in  a  fixed  position, 
the  arching  of  the  lumbar  region  forward  and  the  dorsal  region  backward  being 
necessary  to  maintain  the  equilibrium.  Flexion  and  abduction  combined 
produce  a  compensatory  lordosis  and  lateral  curvature. 

Recovery. 

Amelioration  of  all  the  symptoms,  both  local  and  constitutional,  may 
occur  at  any  period,  but  if  suppuration  has  occurred,  recovery  with  a  shortened, 
somewhat  ankylosed,  and  atrophied  limb  is  all  that  can  be  attained  by 
conservative  measures.  If  the  tendency  is  toward  recovery,  this  will  be 
indicated  by  the  general  improvement  of  all  the  constitutional  and  local 
symptoms.  Gradually  the  sinuses  cease  discharging,  and  finally  close,  the 
swelling  and  induration  diminish,  and  the  limb  becomes  more  or  less  ankylosed 
in  the  position  which  it  has  last  assumed,  either  from  position  of  recumbency 
or  the  use  of  apparatus.  In  mild  cases  without  suppuration,  and  some  cases 
even  with  suppuration,  perfect  motion  may  be  secured  as  the  reward  for  efiicient 
treatment. 

Destruction. 

When  the  disease  progresses  toward  a  fatal  termination  the  adynamia  from 
excessive  suppuration  leads  to  death  from  exhaustion — the  patient  dies  of 
amyloid  degeneration  of  the  internal  viscera,  tubercular  disease  of  some  distant 
organ,  particularly  meningitis,  or  succumbs  from  some  intercurrent  affection 
which  otherwise  would  have  been  successfully  resisted.  When  meningitis 
occurs  Kernig's  sign  —  flexion  of  the  hip,  knee,  and  sometimes  the  elbow- 
joints,  when  the  patient  assumes  the  sitting  position — will  be  of  no  value,  since 
flexion  will  be  present  in  the  hip  from  the  local  affection.  In  doubtful  cases 
lumbar  puncture  should  be  performed. 

Hip  Disease  in  the  Adult. — In  the  adult  hip  disease  is  far  more  serious, 
more  difficult  to  diagnose,  and  more  fatal.  Not  infrequently  it  is  a  secondary 
affection  from  an  early  healed  focus.     The  course  is  less  acute  and  suppuration 


324 


ORTHOPEDIC  SURGERY. 


is  frequent.  It  can  with  difficulty  be  distinguished  from  gonorrheal  and  septic 
arthritis,  osteo-arthritis,  etc.  Early  operation  is  required  more  frequently 
than  in  childhood,  and  mechanical  treatment  is  beset  with  more  difficulties. 

Double  Hip  Disease. — The  course  of  the  disease  differs  somewhat  when 
both  hip-joints  are  affected.  According  to  Ridlon,  the  disease  seldom  begins 
in  both  hip-joints  at  the  same  time,  and  the  second  joint  may  become  diseased 
while  the  patient  is  resting  in  bed  under  treatment  for  the  first  joint,  showing 
that  traumatism  may  be  excluded  as  a  cause  of  the  disease  in  the  second  joint 


Fig.  294. — Last  Stage  of  Hip  Disease. 


in  very  many  cases.  The  joint  first  affected  is  often  the  last  to  recover;  the 
duration  of  the  disease  in  the  first  hip  is  usuahy  somewhat  less  than  in  the  average 
case  of  hip  disease,  while  the  duration  in  the  second  hip  is  usually  much  less 
than  that  in  the  first.  The  amount  of  pain  experienced  in  the  second  hip  is 
usually  less  than  that  of  the  first. 

In  bilateral  hip  disease  the  duration  of  the  disease  in  the  first  hip  is  usually 
somewhat  less  than  that  of  the  average  case  of  hip  disease,  while  the  duration 
in  the  second  hip  is  less  than  that  of  the  first,  the  joint  first  attacked  frequently 
being  the  last  to  recover. 


HIP- JOINT  DISEASE.  325 

Deformity  is  marlced,  and  may  differ  on  the  two  sides,  there  being  adduc- 
tion on  one  side  and  abduction  on  the  other. 

Ankylosis,  with  more  or  less  adduction  in  one  or  both  legs,  may  result 
with  or  without  treatment.  The  result  in  severe  cases  is  a  "scissor-legged" 
deformity ;  locomotion  is  possible,  progression  taking  place  entirely  by  movement 
of  the  knee-joint.  In  females  impregnation  and  safe  delivery  are  likewise 
possible,  though  in  severe  cases  impregnation  can  only  be  accomplished  with 
difficulty,  and  parturition  may  become  impossible  from  the  marked  adduction 
of  the  thighs,  as  in  an  instance  at  the  Philadelphia  Hospital  which  terminated 
fatally.  The  kyphosis  and  other  pelvic  deformities  will  be  much  influenced 
by  the  age  at  which  the  hip  disease  occurs,  and  particularly  upon  the  disturbance 
of  the  normal  anatomic  forces,  as  pointed  out  by  Schroeder. 

Remissions. — Distinct  remissions  of  all  the  symptoms  may  occur,  and 
these  may  be  repeated  many  times.  These  remissions  are  liable  to  occur  in 
the  early  stage  of  the  affection.  A  slight  limp  may  disappear  under  recumbency 
for  a  week,  only  to  return  a  month  or  two  later.  It  may  or  may  not  be 
accompanied  by  pain,  but  upon  careful  examination  a  reflex  muscular  spasm 
will  be  found  to  be  present  during  the  intervals,  and  some  slight  alteration 
in  the  normal  gait  may  be  detected  by  an  experienced  person.  Pain,  when 
present,  as  also  the  soreness,  may  disappear,  and  during  the  interval  the  patient 
may  resume  his  former  activity,  but  subsequently  the  pain,  limp,  and  discomfort 
will  return.  This  may  be  repeated  several  times,  in  one  instance,  reported 
by  Shafl'er,*  as  many  as  seven  times  before  the  disease  became  established. 
Remissions  may  also  occur  in  the  later  stages  of  the  disease,  but,  as  a  rule, 
they  are  not  so  frequent,  and  the  disease  runs  its  course  with  greater 
regularity. 

Diagnosis. 

The  general  diagnostic  signs  of  hip-joint  disease  are  (i)  limitation  of  motion, 
(2)  atrophy,  (3)  lameness,  (4)  attitude  of  limb,  (5)  pain,  and  (6)  sweUing.  These 
should  aU  be  carefully  and  thoroughly  considered  in  arriving  at  a  proper  estimate 
of  the  condition  of  the  joint  in  any  given  case.  The  symptom  of  "grating" 
is  fallacious  except  in  advanced  cases,  in  which  the  associated  symptoms  will 
be  so  positive  that  its  discovery  wifl  add  but  little  of  value.  The  first 
two  symptoms  are  peculiarly  significant  of  hip  disease,  and  upon  them  in -the 


■  "Trans.  Amer.-Orth.  Assoc,"  vol.  xv,  p.  25S. 


326 


ORTHOPEDIC  SURGERY. 


earlier  stages  the  most  reliance  can  be  placed.     Later,  the  attitude  of  the  limb, 
the  pain,  and  the  swelling  are  of  great  diagnostic  importance. 

Limitation  of  Motion. — Being  a  reflex  tetanoid  spasm,  the  first  to  appear, 
the  most  prominent  while  the  disease  exists,  it  is  the  diagnostic  sign  far  excellence 
of  hip  disease.     Its  estimation  in  very  young  children,  who  through  fright 


Fig.  293. — -Test  for  Limitation  of  Flexion  in  Hip  Disease 


Fig.  296. — Examination  for  Limitation  op  Extension  in  Hip  Disease. 


are  apt  to  resist  thorough  examination,  requires  tact  and  patience.  The  examina- 
tion should  always  be  begun  on  the  sound  side  to  secure,  if  possible,  the  confidence 
of  the  patient,  and  flexion,  extension,  adduction,  abduction,  and  rotation  of 
the -thigh,  flexed  at  a  right  angle  to  the  body,  should  each  be  separately  investi- 
gated. 

The  tests  in  young  and  frightened  children  may  be  made  with  the  child 


HIP-JOINT  DISEASE. 


327 


lying  on  the  mother's  lap,  but  are  best  made  with  all  clothing  removed,  upon 
a  hard  table  or  firm  mattress. 

In  the  earlier  stages  of  disease  forced  flexion,  forced  extension,  and  forced 
rotation  alone  may  give  limitation,  motion  being  perfect  throughout  a  large 
portion  of  the  arc  in  each  direction  and  being  limited  only  at  the  extremity 
of  the  arc  of  normal  motion.  Anesthesia  overcomes  the  spasm,  and  hence 
should  not,  for  diagnostic  purposes,  be  employed. 


Fig.  297. — Early  Stage  of  Hip  Disease,  showing  Lordosis. 


Fig.  29S. — Same,  showing  Disappearance  of  Lordosis  on  Flexion  of  Thigh. 


The  patient  upon  the  back,  and  the  pelvis  being  fixed  with  one  hand, 
the  other  should  grasp  the  ankle  of  the  sound  limb  first,  and  firmly  but  gently 
flex  it  until  it  touches  the  abdomen  or  meets  with  resistance.  The  suspected 
limb  should  then  be  flexed  in  a  similar  manner  and  the  resistance,  if  any,  be 
compared;  or  the  patient  in  the  same  position,  the  sound  limb  being  flexed 
upon  the  body  and  held  by  the  hand  of  the  patient,  the  affected  limb  is  then 


328  ORTHOPEDIC  SURGERY. 

examined  for  flexion,  extension,  and  circumduction.  The  pelvis  being  again 
fixed,  abduction  can  be  estimated  by  separating  first  the  sound  limb  and  then 
the  suspected  limb  as  widely  as  possible  from  its  fellow.  Adduction  can  be 
estimated  by  crossing  first  the  sound  limb  and  then  the  suspected  limb 
as  much  as  possible,  the  pelvis  being  fixed.  Extension  is  best  estimated  with 
the  patient  in  the  prone  position.  Fixing  the  pelvis  with  one  hand,  the  sound 
limb  is  flexed  at  the  knee  to  a  right  angle,  and  the  thigh  extended  (backward) 
upward  until  it  meets  with  resistance.  The  suspected  limb  is  likewise  placed 
in  forced  extension  and  the  results  compared. 

The  degree  of  rotation  present  is  best  ascertained  by  rotation  with  the  hip 
flexed  at  a  right  angle  to  the  body. 

In  the  more  advanced  stages  the  estimation  of  limitation  is  easier,  since  the 
pelvis  readily  moves  with  the  affected  limb  before  the  limit  of  motion  is  reached. 
Thus,  in  flexion  from  contraction  of  the  psoas  and  iliacus  muscles  the  popliteal 
space  cannot  (as  on  the  sound  side)  be  placed  upon  the  hard  surface  upon  which 
the  patient  lies  without  the  arching  (lordosis)  of  the  lumbar  region.  Likewise 
the  amount  of  abduction  and  adduction  may  be  estimated  by  placing  one  hand 
upon  the  anterior  superior  spinous  process  of  the  ilium  of  the  sound  side,  and 
gently  but  firmly  abducting  and  adducting  the  suspected  limb,  the  pelvis  moving 
with  the  limb  as  soon  as  the  limit  of  motion  is  reached. 

In  these  estimations  the  greatest  reliance  should  be  placed  upon  limitation 
of  motion  at  the  extremity  of  the  arc  of  normal  motion. 

Atrophy. — Atrophy  of  the  muscles  being  the  result  of  the  reflex  muscular 
spasm,  appears  very  early  in  some  instances  while  the  disease  is  still  confined 
to  the  epiphysis,  and  is  one  of  the  most  important  symptoms  in  arriving  at 
a  correct  early  diagnosis.  The  atrophy  is  not  only  greater  than  that  in  simple 
disease  of  the  muscles,  but  being  unilateral  (in  a  single  hip  disease)  and  being 
confined  to  certain  groups  of  muscles,  is  very  characteristic.  In  the  earliest 
stages  the  adductors  only  are  atrophied,  but  later  the  obliteration  of  the  fold 
of  the  nates  occurs  through  atrophy  of  the  glutei,  and  the  calf  muscles  and  all 
the  thigh  muscles  share  in  the  general  atrophy. 

Mensuration. — Measurement  for  atrophy  is  made  by  taking  the  circum- 
ference at  the  same  level  of  both  the  thighs  and  calves  with  an  ordinary  tape- 
measure. 

For  the  purpose  of  record,  or  where  greater  accuracy  is  desired,  the  levels 
at  which  the  circumferences  are  taken  should  be  measured  from  some  bony 
point.     Thus,  in  measuring  the  thigh  the  writer  prefers  to  take  two  points 


Fig.  299. 

Position  of  tlie  adducted  limb  when  the  pelvis  is 
brought  straight  (Bryant). 


Fig.  300 

Position  of  patient  when  standing  with  disease  of 
the  left  hip-joint  and  an  adducted  limb.  The 
pelvis  is  tilted  up  on  the  affected  side,  and  the 
limb  thereby  apparently  shortened  (Bryant). 


Fig.  301. 

Abducted  position  of  the  diseased  left  limb  when 
the  pelvis  has  been  brought  into  its  natural 
position  at  right  angles  to  the  spine  (Bryant). 


Fig.  302. 

Apparent  elongation  of  the  left  lower  extremity  in 
hip  disease  on  the  left  side,  due  to  abduction 
of  the  limb  and  the  necessary  tilting  upward 
of  the  pelvis  on  the  sound  side  to  allow  of  the 
abducted  limb  being  brought  into  a  line  with 
the  body  (Bryant). 


fir 

Fig.  303. 
Method  of  Kingsley  for  estimation  of  flexion  (Bradford  and  Lovett). 


HIP-JOINT  DISEASE.  331 

measured  in  the  direction  of  the  sartorius  muscle  from  the  internal  condyle, 
three  and  five  inches  or  five  and  seven  inches,  according  to  the  size  of  the 
individual.     The  formula  for  a  child  would  read: 


Sound  limb: 

R.  thigh  @  3"  =  14  ; 

@  5"  =  12.    R.  calf  =  7 

Affected  limb: 

L.  thigh  @  3"  =  13  ; 

@  5"  =  II.    L.  calf  =  7 

Such  measurements  are  of  great  value  for  future  reference.  The  calf  measure- 
ment should  be  taken  through  its  thickest  part.  Atrophy  is  seldom  absent 
where  hip  disease  exists. 

Lameness. — A  limp  in  the  gait  is  one  of  the  earliest  objective  signs  of 
hip  disease,  but  since  it  is  intermittent  in  the  earliest  stage,  and  may  be  exactly 
simulated  by  other  conditions,  as  a  single  positive  sign  it  is  of  little  value. 

Later,  the  attitude  and  fixation  of  the  limb,  and  shortening,  induce  an 
attitude  and  gait  that  are  very  characteristic. 

Attitude  of  Limb. — The  abnormal  position  of  the  thigh  to  the  pelvis 
and  to  the  opposite  thigh  are  due  in  the  early  stages  to  muscular  contraction; 
in  the  later  stages  to  fibrous  or  bony  ankylosis.  Adduction  and  abduction 
are  recognized  by  the  patient,  not  as  lateral  deviations  of  the  thigh,  but  as 
apparent  shortening  or  lengthening  of  the  afliected  limb. 

In  adduction  the  pelvis  is  tilted  upward  on  the  affected  side,  giving  rise 
to  apparent  shortening  of  the  limb;  and  in  abduction  the  pelvis  is  tilted  down- 
ward on  the  affected  side,  giving  rise  to  apparent  lengthening.  This  lateral 
tilting  of  the  pelvis  may  be  recognized  by  drawing  an  imaginary  line  between 
the  anterior  superior  spinous  processes,  which  should  intersect  at  right  angles 
a  line  drawn  from  the  umbilicus  to  the  pubis,  if  the  pelvis  is  in  its  normal  position. 
This  apparent  or  practical  shortening  and  lengthening,  the  result  of  adduction 
and  abduction  respectively,  have  led  to  some  confusion  which  will  require 
explanation.  The  accompanying  diagrams  (Figs.  299  and  302)  will  iUustrate 
this. 

This  obliquity  of  the  pelvis  depends  upon  the  fact  that  in  walking  or  stand- 
ing the  limbs  must  be  made  parallel. 

If,  however  (as  in  Fig.  299),  the  thigh  is  fixed  by  muscular  spasm  or  ankylosis 
in  an  adducted  position,  progression  is  impossible  while  the  affected  limb  crosses 
the  sound  limb.  Elevation  of  the  pelvis  (as  in  Fig.  300)  brings  the  thighs  parallel 
and  permits  of  walking,  but  the  affected  limb  is  apparently  shortened  in 
proportion  to  the  degree  of  adduction  present. 

In  the  same  manner,  if  (as  shown  in  Fig.  301)  the  thigh  be  abducted, 
progression  is  impossible  while  the  limbs  are  so  widely  separated.     Lowering 


332  ORTHOPEDIC  SURGERY. 

of  the  pelvis  (as  shown  in  Fig.  302)  brings  the  thighs  parallel,  but  the  affected 
limb  is  apparently  lengthened  in  proportion  to  the  degree  of  abduction  present. 

The  position  recommended  as  best  suited  for  examination  is  that  in  which 
the  sound  and  affected  limbs  are  parallel ;  the  nature  and  amount  of  the  obliquity 
of  the  pelvis  as  it  affects  the  diseased  side  is  then  more  evident  than  when  the 
pelvis  and  sound  side  are  perfectly  straight.  For  measurement  of  the  apparent 
and  practical  shortening  or  lengthening,  the  position  best  suited  is  that  in  which 
the  trunk  and  the  sound  side  are  perfectly  straight.  The  practical  measure- 
ments are  then  made  with  an  ordinary  tape-measure  from  the  umbilicus  to  each 
malleolus.  Thus,  in  adduction  the  tilting  of  the  pelvis  has  caused  a  practical 
shortening  of  the  affected  limb,  and  in  abduction  the  opposite  tilting  of  the 
pelvis  has  caused  a  practical  lengthening  of  the  diseased  member. 

Real  or  bone  shortening  results  from  destruction  of  bone  from  disease 
or  retarded  growth,  and  is  a  permanent  condition.  It  is  best  estimated  by 
measuring  from  the  anterior  superior  spinous  process  to  the  malleolus  on  each 
side.  Real  shortening  is  sometimes  due  to  spontaneous  dislocation  from  disease. 
In  such  cases  the  degree  of  subluxation,  or  the  amount  of  change  in  the 
acetabulum,  may  be  estimated  by  ascertaining  the  relation  of  the  great  trochanter 
to  the  Roser-Nelaton  line.  Thus,  with  the  affected  thigh  slightly  flexed,  if 
a  line  be  drawn  from  the  anterior  superior  spinous  process  to  the  most  prominent 
part  of  the  tuberosity  of  the  ischium,  it  should  pass  immediately  above  the 
upper  border  of  the  trochanter.  If  there  is  any  alteration  of  this,  luxation 
is  evident,  and  its  degree  may  be  estimated. 

The  degree  of  adduction  or  abduction  may  be  estimated  with  a  goniometer, 
or  joint  measure.  The  horizontal  arm  is  placed  upon  the  anterior  superior 
spinous  process;  the  vertical  arm  is  then  placed  parallel  with  the  diseased  limb, 
and  the  degree  of  deformity  estimated.  To  estimate  flexion  or  extension  with 
the  goniometer  the  instrument  rests  with  the  graduated  arc  against  the  body 
over  the  affected  joint,  with  the  horizontal  arm  in  the  line  of  the  body.  The 
movable  arm  rests  against  the  limb  parallel  with  its  popliteal  axis,  while  the 
index  records  the  degree  of  deformity. 

A  simpler  and  more  accurate  method  is  that  introduced  and  employed 
by  Lovett,  of  Boston.*  It  is  based  upon  the  mathematic  relationship  existing 
between  real  and  practical  shortening.  The  measurements  with  the  patient 
lying  straight  are  taken  in  the  usual  way,  with  an  ordinary  tape-measure — 

*"  Boston  Med.  and  Surg.  Jour.,"  March  S,  iSSS. 


HIP-JOINT  DISEASE.  333 

i.  e.,  the  real  or  bone  shortening  is  measured  from  the  anterior  superior  spinous 
processes  to  each  malleolus,  and  the  apparent  or  practical  shortening  is  measured 
from  the  umbilicus  to  each  malleolus.  An  additional  measurement  between 
the  spinous  processes  is  necessary  to  complete  the  data.  Upon  these  Lovett 
has  constructed  an  elaborate  table,  and  deduced  the  following  rule:  "If  the 
practical  shortening  is  greater  than  the  real  shortening,  the  diseased  leg  is 
adducted;  if  less  than  real  shortening,  it  is  abducted."  For  example:  Length 
(from  anterior  superior  spinous  process)  of  right  leg,  23  inches;  left  leg,  22^ 
mches;  length  (from  umbilicus)  of  right  leg,  25  inches;  left  leg,  23  inches; 
real  shortening  i\  inches,  apparent  shortening  2  inches;  difference  between 
real  and  practical  shortening,  ij  inches;  pelvic  measurement,  between  spines 
7  inches.  By  following  the  line  i\  inches  until  it  intersects  the  line  for  pelvic 
measurement  of  7  inches,  22°  is  found  to  be  the  angle  of  deformity,  and  as 
the  practical  shortening  is  greater  than  the  real,  it  is  12°  of  adduction  of  the 
left  thigh. 

Distance  in  inches  between  anterior  superior  spines. 


3 

3* 

4 

Ah 

s 

s* 

6 

6i 

7 

■h 

SJ 

9 

9i 

10 

II 

12 

13 

_ 

} 

5° 

4° 

4° 

f 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

1° 

1° 

1° 

1° 

1° 

a 

* 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

% 

i 

14 

12 

II 

10 

8 

S 

7 

7 

6 

6 

5 

5 

4 

4 

4 

3 

3 

? 

J 

19 

17 

14 

13 

II 

10 

9 

9 

S 

7 

7 

6 

6 

6 

5 

5 

4 

1 

li 

25 

21 

18 

16 

14 

13 

12 

II 

10 

9 

8 

S 

7 

7 

7 

6 

6 

I* 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

10 

la 

9 

9 

8 

7 

7 

1 

li 

36 

3° 

26 

23 

20 

18 

17 

15 

14 

13 

12 

II 

10 

10 

9 

8 

8 

1 

' 

42 

35 

3° 

26 

23 

21 

19 

18 

16 

15 

14 

13 

12 

12 

10 

10 

9 

^  ■ 

2i 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

II 

10 

2i 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

II 

.0 

=5 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

1 

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42 

35 

32 

29 

27 

25 

23 

22 

21 

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iS 

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16 

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13 

■2 

3} 

39 

36 

32 

3° 

27 

26 

25 

22 

21 

20 

19 

J7 

15 

14 

g 

i\ 

40 

35 

33 

3° 

28 

26 

24 

23 

22 

21 

19 

17 

16 

1 

3i 

3S 

35 

32 

3° 

28 

26 

25 

23 

22 

20 

18 

17 

Q 

^ 

42 

38 

35 

32 

3° 

28 

26 

25 

23 

21 

10 

iS 

The  amount  of  flexion  in  degrees  may  be  estimated  in  a  similar  manner, 
after  the  method  of  Kingsley,  of  Boston.*  The  patient  lies  on  his  back  upon 
a  table  or  other  hard  flat  surface,  and  the  surgeon  flexes  the  diseased  leg  by  the 
heel  until  the  lumbar  vertebras  touch  the  table  (Fig.  303),  showing  that  the  pelvis 
is  in  the  normal  position,  and  the  angle  (a  b  c)  which  the  leg  makes  with  the 


*  "Boston  Med.  and  Surg.  Jour.,"  July  5,  1888. 


334  ORTHOPEDIC  SURGERY. 

table  is  the  angle  of  flexion  of  the  thigh  from  the  normal  position.  In  this 
position  the  surgeon  measures  off  two  feet  on  the  external  aspect  of  the  leg 
with  a  tape  measure,  one  (the  zero)  end  of  which  is  held  on  the  table,  in  the 
direction  of  the  line  of  the  leg  (a  b).  From  this  point  (b)  one  measures  the 
perpendicular  distance  in  inches  to  the  table  (c),  and  from  the  number  of  inches 
in  this  line  (b  c)  can  be  ascertained  in  the  table  the  degrees  of  flexion  of  the 
thigh  from  the  normal  position.  For  example,  if  the  distance  between  the 
point  on  the  leg  and  the  table  is  lo  inches,  25  degrees  flexion  of  the  thigh  are 
present. 


Inches. 

Degrees. 

Inches. 

Degrees. 

Inches. 

Degrees. 

.Indies. 

Degrees. 

0-5 

I 

6-5 

16 

12-5 

31 

18.5 

50 

I.O 

2 

7.0 

17 

13.0 

ii 

19.0 

52 

1-5 

3 

7-S 

19 

13-5 

34 

19-5 

54 

2.0 

4 

8.0 

20 

14.0 

36 

20.0 

56 

2-S 

6 

8.5 

21 

I4-S 

37 

20.5 

58 

3-0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3-S 

9 

9-5 

24 

iS-5 

40 

21-5 

63 

4.0 

10 

lO.O 

25 

16.0 

42 

22.0 

67 

4-S 

II 

lo.s 

27 

16.S 

43 

22.5 

70 

S-o 

12 

II.O 

28 

17.0 

43 

23.0 

75 

l-i 

14 

II-5 

29 

17-5 

47           i 

^3-S 

80 

6.0 

IS 

12.0 

3° 

18.0 

48           ; 

1 

24.0 

90 

If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off  24  inches,  one 
may  measure  12  inches;  from  this  point  ascertain  the  distance  to  the  table 
in  a  prependicular  line  just  as  before,  double  this  distance,  and  look  as  before 
for  the  amount  of  flexion  present. 

Pain. — Pain  may  be  absent  in  any  or  all  the  stages  of  hip  disease,  but 
the  characteristic  pain  is  usually  experienced  in  the  affected  joint  or  in  the 
corresponding  knee.  The  latter  is  often  intermittent,  and  usually  signifies 
the  femoral  form  of  disease.  Pain  in  the  arthritic  form  is  constant,  acute, 
and  accompanied  with  a  feeling  of  tension  and  tenderness  above  the  great 
trochanter.  Tenderness  and  pain  on  jarring  the  hip  or  on  motion  are  more 
marked  in  the  acetabular  variety.  Pain  elicited  by  striking  on  the  knee  or 
heel,  and  thus  pressing  the  joint  surfaces  together,  is  untrustworthy,  and  as  a 
diagnostic  sign  should  be  abandoned. 

Swelling. — Local  swelling  is  considered  as  one  of  the  most  important 
symptoms.  It  is  most  marked  in  the  arthritic  variety,  which  may  be  considered 
the  acute  form  of  the  disease.  Confined  to  the  front  and  back  of  the  joint, 
it  indicates  effusion  into  the  synovial  sac;  confined  to  the  great  trochanter, 
it  has  been  considered  pathognomonic  of  suppuration  within  the  joint.     Thicken- 


HIP- JO  INT  DISEASE.  335 

ing  of  the  great  trochanter  as  a  late  symptom  is  of  some  vahie  as  a  confirmatory 
sign,  but  swelhng  and  thickening  alone  are  of  but  little  importance. 

In  conclusion,  the  general  diagnostic  signs  of  hip-joint  disease  are  limitation 
of  motion,  atrophy,  lameness,  attitude  of  limb,  pain,  and  swelling;  and  of 
these,  the  first  two  are  peculiarly  significant  of  early  disease,  while  later  are 
added  the  attitude  of  the  limb  and  swelling. 

Differential  Diagnosis. 

Many  diseases  have  been  mistaken  for  hip  disease  through  ignorance 
of  its  characteristic  symptoms,  or  at  a  very  early  period  of  the  disease.  The 
diagnosis  of  contusions  and  sprains  can  readily  be  ascertained  by  exclusion, 
and  of  muscular  rheumatism  of  the  hip  by  the  inherited  or  acquired  history 
of  the  affection,  the  lameness  preceding  the  pain,  the  absence  of  reflex  muscular 
spasm,  and  local  hyperesthesia,  perinephritis,  perityphlitis,  rachitis,  and  pseudo- 
hypertrophy are  entirely  dissimilar,  and  do  not  require  consideration. 

Hip  disease  could  only  be  mistaken  for  abscess  external  to  the  joint,  for 
disease  of  the  knee,  or  for  caries  of  the  great  trochanter,  by  neglect  of  careful 
examination. 

The  diagnosis  from  separation  of  the  upper  epiphysis  of  the  femur  with 
abscess  is  difficult,  if  not  impossible — a  matter  which,  fortunately,  is  of  no 
practical  moment,  as  excision  would  be  equally  indicated  in  either  affection. 
The  same  may  be  said  of  the  differential  diagnosis  of  traumatic,  rheumatic,  or 
blennorrhagic  arthritis  from  the  arthritic  variety  of  morbus  coxarius,  since 
conservative  treatment  would  be  indicated  in  either  affection. 

There,  are  however,  several  afl"ections  commonly  mistaken  for  hip  disease 
which  deserve  thorough  consideration.     They  are  as  follows: 

1.  S3movitis  of  the  hip-joint. 

2.  Lumbar  Pott's  disease. 

3.  Periarthritis. 

4.  Infantile  spinal  paralysis. 

5.  Congenital  dislocation. 

6.  Sacro-iliac  disease. 

7.  Hysteric  affections. 

Synovitis  of  the  Hip-joint. — The  greatest  difficulty  will  be  experienced 
in  distinguishing  acute  primary  synovitis  from  the  arthritic  form  of  chronic 
articular  osteitis.  The  acute  nature  of  the  affection,  the  short  course,  the 
absence  of  muscular  spasm  and  atrophy,  with  eversion  and  outward  rotation 


336  ORTHOPEDIC  SURGERY. 

of  the  limb,  are  all  of  value  in  distinguishing  synovitis.  The  acute  form  may, 
however,  become  chronic,  and  a  number  of  orthopedic  surgeons  still  favor 
the  possibility  of  a  synovitis  eventually  becoming  an  osteitis.  Of  this  nature 
undoubtedly  is  the  so-called  arthritic  variety  of  hip  disease.  Of  such  nature 
are  the  cases  with  marked  characteristic  symptoms  which  recover  promptly  and 
permanently  within  a  few  months. 

From  synovitis  the  following  considerations  will  be  sufficient  to  establish 
the  distinction: 

Synovitis.  Chronic  Asticular  Osteitis. 

1.  Pain  coincidental   with   lameness,   and   invasion       i.  Pain  preceded  by  lameness,  and  invasion  seldom 

sharp  and  clear.  if  ever,  sharply  defined. 

2.  Locomotion  speedily  impossible.  2.  Locomotion  continues  possible. 

3.  Occurs  after  eighth  year.  3.  Occurs  before  eighth  year. 

4.  Joint  tenderness  present.  4.  Joint  tenderness  absent. 

5.  No  bone  tenderness  nor  periarticular  or  articular  5.  Bone  tenderness  early;    infiltration  beginning   of 

infiltration.  second  stage. 

6.  Muscular  atrophy  absent.  6.  Muscular  atrophy  present. 

7.  Rotation,  eversion,  and  apparent  elongation.  7.  Limbs  parallel  in  early  stage. 

Lumbar  Pott's  Disease.^In  the  early  stage  of  lumbar  Pott's  disease 
it  is  difficult  and  in  some  instances  almost  impossible  to  arrive  at  a  positive 
diagnosis  from  hip  disease  until  the  symptoms  become  more  thoroughly  estab- 
lished. Among  the  first  symptoms  may  be  a  limp  and  limitation  of  motion 
in  one  limb  from  irritation  or  the  presence  of  pus  in  the  psoas  muscle.  This 
limitation  of  motion  is  confined  usually  to  forced  extension,  but  later,  from 
extension  of  the  pus  as  a  psoas  abscess,  limitation  of  all  motion  at  the  hip  will 
still  further  complicate  the  diagnosis.  In  either  event  the  presence  of  muscular 
spinal  rigidity  from  reflex  spasm  will  determine  the  true  nature  of  the  affection, 
due  allowance  being  made  for  the  spasmodic  contraction  upon  manipulation 
of  these  muscles  in  hip  disease.  The  amount  of  abduction  present  in  the  hip- 
joint  is  also  important,  since  abduction  is  very  early  lost  in  hip-joint  disease, 
while  it  often  remains  free  in  advanced  cases  of  psoas  irritation  and  contraction. 
In  advanced  cases  of  lumbar  Pott's  disease,  where  psoas  abscess  is  in  contact 
with  and  irritates  the  hip-joint,  it  is  extremely  difficult  to  ascertain  whether 
or  not  hip-joint  disease  coexists.  The  amount  of  abduction  and  rotation  present, 
and  the  effect  of  rest  and  quiet  to  the  joint,  will  best  determine  the  exact 
condition.  In  conclusion,  in  lumbar  Pott's  disease  the  following  peculiarities 
will  be  of  service  in  arriving  at  a  correct  diagnosis:  The  lameness  is  subject 
to  complete  remissions,  depends  upon  psoas  contraction,  and  has  more  lordosis 
associated;   the  patient  can  stand  as  well  upon  the  lame  limb  as  upon  the 


HIP-JOINT  DISEASE.  337 

otlicr,  and  retiex  muscular  spasm  is  never  excited  by  passive  motion  of  the 
lame  hip.  INIoreover,  the  pain  and  stiffness  are  usually  present  in  the  morn- 
ing in  lumbar  Pott's  disease  and  pass  away  during  the  day,  whereas  in  hip  dis- 
ease they  are  absent  in  the  morning  and  more  rnarked  toward  the  close  of 
the  day. 

Periarthritis. — It  is  only  in  the  very  early  stage  and  only  in  phlegmonous 
inflammations  about  the  joint  that  much  difficulty  is  experienced,  since  the 
fibrous  form  does  not,  as  a  rule,  occur  in  children.  Under  this  head  may  be 
included  inflammation  of  bursal  and  lymphatic  glands  and  psoas  abscess. 
The  acuteness  of  the  attack,  the  history  of  traumatism,  the  rapid  development 
of  the  physical  signs  of  acute  abscess,  the  constitutional  disturbance,  the  absence 
of  reflex  muscular  spasm  and  atrophy,  and  the  osteitic  "night-cry,"  would  serve 
to  distinguish  periarthritis. 

The  movements  of  the  muscles,  whose  mechanical  execution  is  interfered 
with  by  inflammation,  is  limited,  but  the  reflex  element  is  absent,  as  likewise 
it  is  in  cases  of  sarcoma  of  the  hip,  in  which  the  greater  hardness  of  the  swelling, 
as  well  as  the  absence  of  the  typical  symptoms,  would  distinguish  it. 

Infantile  Spinal  Paralysis. — ^In  the  initial  stage  of  infantile  spinal 
paralysis,  the  age,  tottering  walk,  history  of  fall,  accentuation  of  pains,  and 
hyperesthesia  of  the  joint  closely  correspond  to  early  hip  disease.  Later, 
the  absence  of  pain  and  swelling,  the  abnormal  mobility,  the  extreme  atrophy 
of  the  whole  limb,  and  coldness  render  the  diagnosis  patent.  Acute  hip  disease 
may,  however,  occur  in  a  leg  affected  by  infantile  paralysis.  The  dift'erential 
points  which  establish  the  diagnosis  in  infantile  spinal  paralysis  are:  the 
character  of  the  walk,  which  is  a  tottering,  not  a  stiff  gait ;  the  absence  of  reflex 
muscular  spasm  and  abscess ;  the  degeneration  reactions  given  with  the  galvanic 
current,  the  normal  formula  of  C  C  C  >  A  C  C  being  re^Trsed  (inde  Infantile 
Spinal  Paralysis);  and  the  loss  of  the  faradic  reaction  within  the  first  week, 
an  important  and  easy  diagnostic  point  for  the  general  practitioner. 

Congenital  Dislocation. — The  persistent  limp  and  the  pain  of  sprains 
from  repeated  falls  are  the  only  symptoms  in  congenital  dislocation  which 
have  any  resemblance  to  hip-joint  disease,  but  the  congenital  nature  of  the 
limp,  the  excessive  mobility  of  the  joint,  the  entire  absence  of  reflex  muscular 
spasm  or  limitation  of  motion,  and,  in  fact,  of  all  the  important  symptoms 
of  the  latter  disease,  lead  to  its  easy  recognition.  With  the  aid  of  a  skiagraph 
the  differential  diagnosis  can  readily  be  made.  In  congenital  dislocation  the 
displacement  of  the  head  of  the  femur  will  be  observed  with  a  perfect  contour 

23 


338  ORTHOPEDIC  SURGERY. 

of  the  articulating  surfaces,  whereas  in  hip-joint  disease,  even  if  so-called 
dislocation  has  occurred,  the  erosion  or  destruction  of  the  part  of  the  head 
will  be  noticed.  ^Moreover,  congenital  luxation  is  more  frequently  bilateral 
than  is  hip  disease. 

Sacro-iliac  Disease. — This  aiJection  imitates  hip-joint  disease  in  the 
lameness,  pain  when  the  joint  surfaces  are  pressed  together,  elongation  of  the 
limb,  and  often  in  the  presence  of  abscesses.  It  difJers  from  hip  disease  in 
that  the  seat  of  greatest  tenderness  is  different,  the  limb  is  not  abducted,  there 
is  no  shortening,  and  no  pain  on  moving  the  hip  if  the  pelvis  be  fixed,  nor  from 
pressure  on  the  trochanter  and  counter-pressure  on  the  tuber  ischii ;  the  patient 
inclines  the  body  to  the  opposite  side  and  not  forward  in  walking,  and  the 
pelvic  distortion  is  permanent  and  absolute,  and  not,  as  in  hip  disease,  temporary 
and  relative.  The  skiagraph  will  be  of  great  ser\-ice  in  differentiating  hip-joint 
disease  from  sacro-iliac  disease,  the  tubercular  lesion  being  distinctly  noted 
in  either  case. 

Hysteric  Affections. — Functional  joint  disease  of  the  hip  occurring 
in  young  anemic  women,  particularly  of  the  upper  class,  coincides  closely  with 
the  bona  fide  organic  disease.  As  coxalgie  hysUriqiie  it  is  exceptionally  rare 
in  men,  Charcot  having  observed  but  one  case  in  the  Salpetriere.  Pain,  which 
is  so  exquisite  as  to  resent  the  slightest  contact,  is  localized  in  the  region  of 
Poupart's  ligament,  over  the  sacrum,  or  in  the  lower  part  of  the  thorax.  The 
limb,  rigidly  fixed  during  any  manipulation,  relaxes  under  gentle  pressure 
when  the  attention  is  withdra'n-n  or  the  examination  completed ;  the  nutrition 
of  the  limb  is  intact;  there  is  no  trace  of  muscular  atrophy.  The  greatest 
diflicultyis  experienced  where  the  neurotic  element  exaggerates  a  true  arthropathy. 
In  such,  a  true  estimate  can  only  be  made  by  the  discovery  that  the  symptoms 
are  out  of  all  proportion  to  the  objective  signs.  A  correct  diagnosis  may  be 
made  by  observing  the  presence  of  an  inherited  or  acquired  neurotic  diathesis; 
the  simultaneous  appearance  of  pain  and  lameness;  the  correspondence  of 
the  areas  of  hyperesthesia  and  paresthesia  to  the  distribution  of  certain  nerve- 
branches;  the  yielding  readUy  to  forced  movements  of  the  muscular  spasm 
about  the  joint,  and  the  effect  of  anti-neurotic  medication  upon  the  disease. 
In  the  later  stage  anesthesia  will  be  an  important  aid,  since  the  muscular  rigidity 
of  the  neuro-mimetic  coxalgia  will  disappear  under  its  administration,  while 
the  permanent  contraction  of  hip-joint  disease  will  remain.  If  any  doubt 
exists  after  the  administration  of  the  anesthetic,  a  skiagraph  would  be  of  great 
service  in  rendering  the  diagnosis  positive. 


HIP-JOINT  DISEASE.  339 

Prognosis. 

Hip  disease  tends  to  recovery,  with  more  or  less  deformity  in  the  majority 
of  cases,  the  prognosis  in  individual  cases  being  directly  influenced  by  the 
age  of  the  patient,  the  variety  of  the  disease,  the  association  of  complications, 
and  the  efficiency  of  treatment.  The  prognosis  is  likewise  affected  by  the 
hygienic  surroundings  and  social  status  of  the  patient,  the  mortality  being 
much  higher  in  dispensary  and  hospital  than  in  private  cases.  When  the 
disease  makes  its  appearance  after  puberty,  it  is  less  manageable,  more  extensive, 
and  more  often  fatal  than  when  it  occurs  at  an  earlier  period. 

In  the  arthritic  variety  of  the  affection  the  prognosis  is  most  favorable, 
being  more  serious  in  the  femoral,  and  still  more  grave  in  the  acetabular  variety. 
The  coexistence  of  some  grave  organic  disease  of  an  internal  organ,  as  nephritis, 
phthisis,  tubercular  meningitis,  or  caries  of  some  other  portion  of  the  skeleton, 
as  the  vertebras,  renders  the  prognosis  most  unfavorable. 

In  a  like  manner  does  efficient  treatment,  early  commenced,  favorably 
influence  the  subsequent  course  and  termination  of  the  disease.  Spontaneous 
recovery  of  extremely  severe  cases  sometimes  occurs,  but  the  early  emplo3Tnent 
of  proper  and  efficient  treatment  will  prevent  complications  and  otherwise 
directly  and  favorably  influence  the  prognois  in  all  cases. 

The  prognosis  will  differ  in  the  different  varieties.  In  the  acute  tubercular 
form  the  prognosis  is  not  so  favorable  as  in  the  chronic  ulcerative,  the  disease 
being  much  more  rapid  and  acute  in  the  former,  and  the  mortality  higher.  In 
the  second  or  chronic  ulcerative  form  the  prognosis  is  most  satisfactory  under 
efficient  treatment,  unless  there  are  complications.  In  the  third  or  chronic 
tubercular  form  the  disease  is  less  acute  and  the  prognosis  is  less  favorable 
than  in  the  second  group,  but  more  favorable  than  in  the  first  group. 

Under  prognosis  the  results  of  efficient  treatment,  relapses,  the  causes 
of  death,  the  time  required  for  treatment,  the  prognosis  in  double  hip  disease, 
and  the  effect  of  operation  upon  the  prognosis,  must  all  be  considered. 

Efl&cient  Treatment. — The  mortality  in  all  cases  which  have  been  under 
treatment  varies  from  7  per  cent,  to  73.2  per  cent.,  the  increased  mortality 
in  all  cases  being  directly  influenced  by  the  absence  or  presence  of  suppuration 
and  complications.  The  mortality  is  greater  in  hospital  than  in  private  practice, 
and  it  also  appears  to  be  higher  in  Germany  than  in  this  country.  In  my  own 
statistics  there  were  13  deaths  in  421  cases.  Thus,  in  the  Alexandra  Hospital, 
London,  there  were  100  deaths  in  384  cases,  a  mortality  of  26  per  cent. ;  of  these, 
260  were  suppurating  cases,  among  which  the  mortality  was  33.5  per  cent.; 


340  ORTHOPEDIC  SURGERY. 

whereas  in  the  CHnical  Society's  Report,  in  1880,  the  mortality  reached  30.4 
per  cent,  in  the  suppurating,  and  about  7  per  cent,  in  the  non-suppurating. 

Cazin  reports  that  in  80  suppurative  cases  treated  at  the  hospital  in  Berck, 
France,  12  per  cent.  died. 

Gibney  reports  that  in  288  cases,  48  of  which  had  abscesses,  122  per  cent, 
died. 

Jacobson  records  73.2  per  cent,  of  deaths  out  of  6^,  suppurating  cases 
that  were  treated  without  operation. 

Wright  found  that  in  100  cases  treated  without  operation,  only  35  of  which 
could  be  traced  as  to  sequel,  9  were  unrelieved  or  relapsed,  and  9  died,  or  25.2 
per  cent. 

In  the  more  recent  reports  the  mortality  was  as  follows: 
Mummelthy,  of  Kiel,  reports  48.59  per  cent,  in  non-operative  cases  and 
53.96  per  cent,  in  operative  cases. 

Marsch,  of  INIarburg,  reports  35  per  cent,  in  non-operative,  and  40.4  per 
cent,  in  operative  cases. 

Huismans,  of  Heidelberg,  reports  46.6  per  cent,  in  non-operative  cases 
and  58  per  cent,  in  operative  cases. 

Pedolin,  of  Zurich,  reports  37.7  per  cent,  in  non-operative  cases  and  54 
per  cent,  in  operative  cases. 

The  death-rate  from  hip  disease  is  small  in  private  practice.  Thus,  Sayre 
in  212  cases  had  only  5  deaths,  Lorenz  in  60  cases  only  3  deaths,  and  Taylor 
in  94  cases,  24  of  which  were  suppurative,  had  only  3  deaths. 

The  mortality  in  all  cases  of  chronic  arthritis  of  the  hip-joint  may  be  said 
to  range  between  7  per  cent,  and  30  per  cent. 

Relapse. — The  frequency  of  relapse  is  also  shown  in  these  statistics, 
there  being  9  unrelieved  or  relapsed  in  35  cases  treated  by  Wright,  and  6  relapsed 
in  the  51  cured  cases  investigated  by  Shaffer  and  Lovett.  Relapses  result  from 
the  infliction  of  fresh  injury,  the  too  early  use  of  the  limb,  or  are  induced  by 
the  failure  of  the  health  from  intercurrent  disease,  as  scarlet  fever,  measles,  etc., 
and  consequently  influence  the  prognosis.  In  such  cases  it  is  important  to 
distinguish  between  true  relapse  and  a  residual  abscess,  the  latter  being  the  result 
of  irritation  of  some  local  product  of  former  disease,  with  little  tendency  to 
spread,  the  former  demonstrating  a  lack  of  sound  repair  in  the  original  lesion 
and  tending  to  progress,  as  in  the  first  instance. 

The  reports  of  the  results  of  conservative  treatment  would  tend  to  emphasize 
the  importance  of  the  influence  of  treatment  upon  the  prognosis  in  this  disease. 


HIP- JOINT  DISEASE.  341 

In  the  80  cases  treated  by  Gibney*  by  internal  medication  and  counter- 
irritation  alone,  at  the  end  of  the  disease — which  ran  its  course  in  33  cases  in 
three  years,  in  28  cases  in  from  three  to  six  years,  and  in  19  cases  in  from  six 
to  ten  years — 61  of  the  patients  could  walk  well,  and  run  without  discomfort; 
12  walked  only  fairly,  requiring  a  support  at  times,  and  7  could  not  walk  without 
crutches.  In  these  80  cases,  12  had,  at  least,  an  arc  of  15  degrees  motion  in 
the  diseased  joint,  the  shortening  amounting,  in  the  majority  of  cases,  to  from 
one  to  three  inches.     Abscesses  had  existed  in  48  cases. 

In  a  more  recent  series  of  cases  reported  by  Gibneyf  in  107  cured  cases 
treated  by  mechanical  and  operative  methods,  the  following  results  were  shown : 

No  flexion, 47 

Flexion  of  10  degrees, 30 

Flexion  of  10  to  20  degrees 20 

Flexion  of  20  to  30  degrees, 10 

Perfect  motion  retained 13 

Good  motion  retained 22 

Limited  motion  retained 41 

Ankylosis  in 31 

Of  the  41  cases  who  remained  well  of  the  51  cases  recorded  by  Shaffer 
and  Lovett,  none  were  incapacitated  from  doing  a  full  day's  work  at  his  or 
her  trade  or  occupation,  and  only  one,  a  boy,  who  had  suffered  from  associated 
Pott's  disease,  used  a  cane. 

In  the  76  cases  more  recently  reported  by  Mr.  Howard  Marsh, {  the  favorable 
results  of  conservative  mechanical  (fixation)  treatment  are  well  shown.  Of 
37  suppurative  cases  one  year  after  discharge,  recoveries  were  perfect  in  i, 
excellent  in  6,  good  in  17,  and  moderate  in  13.  In  39  non-suppurative  cases 
recoveries  were  perfect  in  9,  excellent  in  9,  good  in  12,  and  moderate  in  9.  The 
average  amount  of  shortening  was  two-thirds  of  an  inch,  while  50  per  cent, 
had  a  degree  of  movement  in  the  affected  joint  classed  as  "free  movement." 

Causes  of  Death. — Death  in  hip  disease  may  occur  from  the  general 
dissemination  of  tuberculosis,  as  in  tubercular  meningitis,  phthisis  pulmonalis, 
or  general  miliary  tuberculosis;  from  lardaceous  disease  of  internal  viscera; 
from  pyemia  and  septicemia;  from  exhaustion  from  suppuration;  from  inter- 
current disease,  as  measles,  scarlatina,  etc. ;  and  from  operation.     The  mortality 


*  "N.  Y.  Med.  Rec,"  March  2,  1S7S. 

t  Gibney,  Waterman,  and  Reynolds:  "Transactions  Amer.  Orth.  Assoc,"  1S9S,  vol.  xi. 

t"  British  Medical  Journal,"  August  3,  1889. 


342  ORTHOPEDIC  SURGERY. 

is  increased  by  suppuration;  thus,  in  the  statistics  collected  by  Bruns  the 
mortality  in  the  suppurative  cases  was  52  per  cent.,  and  in  the  non-suppurative 
cases  23  per  cent.  Of  the  614  cases  recently  analyzed  at  the  Alexandra  Hos- 
pital, there  were  35  deaths,  as  follows:  meningitis,  12;  disease  of  the  lungs,  5- 
amyloid  disease,  9 ;  following  amputation,  3 ;  exhaustion,  2 ;  uncertain,  4.  Of 
the  96  deaths  after  suppurative  hip  disease  at  the  same  hospital,  there  were 
from  meningitis,  16.7  per  cent.;  albuminuria  and  dropsy,  20.8  per  cent.; 
phthisis,  5.2  per  cent.;  phthisis  and  albuminuria,  3.1  per  cent.;  exhaustion, 
9.4  per  cent.;  erysipelas  and  pyemia,  3.1  percent.;  intercurrent  disease,  7.3  per 
cent.;  and  after  operation,  9.4  per  cent.;  unknown,  25.0  percent.  In  the  Clini- 
cal Society's  report,  1881,  in  260  cases  with  suppuration  treated  without  excision, 
30.4  per  cent,  died  from  causes  connected  with  the  disease,  of  which  9.2  per 
cent,  died  from  tubercular  disease;  and  in  124  cases  without  suppuration 
treated  without  excision,  the  total  mortality  was  10.5  per  cent.,  of  which  7 
per  cent,  died  of  tuberculosis.  In  the  same  report  of  Mr.  Croft's  45  cases  of 
excision,  7  cases  died  from  results  of  operation,  and  in  Mr.  Bryant's  and  Mr. 
Baker's  203  cases  of  excision,  13.7  per  cent,  died  directly  from  the  operation. 

In  a  report  of  778  patients  suffering  from  hip  disease  in  the  New  York 
Orthopedic  Dispensary  there  were  50  deaths,  the  causes  of  which  were  as  follows : 

Tuberculous  meningitis, 20 

Amyloid  degeneration, 5 

Phthisis, 3 

Exhaustion, 3 

Tuberculous  peritonitis, i 

Sepsis, I 

Convulsions, i 

Unknown, 16 

Time  Required  for  Treatment. — Cases  of  hip  disease  under  thorough 
and  efi&cient  conservative  treatment  will  require  from  two  to  four  years 
permanently  to  establish  a  cure,  and  without  mechanical  treatment  the  disease 
will  run  its  course  in  from  three  to  ten  years. 

Thus,  in  the  39  cured  cases  reported  by  Shaffer  and  Lovett,  31  required 
from  two  to  four  years  to  effect  a  cure,  and  the  remaining  8  from  four  and  a 
half  to  eight  years. 

In  the  80  cured  cases  reported  by  Gibney,  33  ran  their  course  in  three 
years,  28  in  from  three  to  six  years,  and  19  in  from  six  to  ten  years.  Even 
after  all  the  signs  have  disappeared,  it  is  better  for  a  time  to  continue  the  use 
of  the  splint,  or  to  substitute  a  convalescent  splint  in  order  to  avoid  relapse. 


HIP-JOINT  DISEASE. 


34.3 


Amount  of  Deformity. — Mild  cases  may  recover  with  perfectly  free 
motion  and  without  either  deformity  or  shortening  (Figs.  304-306) ;  but  where 
suppuration  has  occurred,  and  particularly  in  the  femoral  and  arthritic  varieties, 
unless  persistent  precautions  have  been  taken  with  regard  to  position,  ankylosis 
with  great  deformity  will  ensue.  If  ankylosis  occur,  the  position  of  the  limb 
as  regards  locomotion  is  most  important.  Obviously  the  less  the  flexion  and 
abduction,  the  more  favorable  the  position.  Even  severe  grades  of  distortion 
may,  however,  subsequently  be  entirely  reinoved  by  osteotomy. 

A  perfect  recovery  from  hip  disease  would  be  shown  by  the  patient  being 
able  to  take  certain  positions  as  well  with  the  cured  limb  as  with  the  limb  which 


Fig.  304. 


Fig.  305. 


Fig.  306. 


Author's  cured  case  of  disease  of  the  right  hip- joint,  one-fourth  inch  shortening,  showing:  Fig.  304,  exten- 
sion; Fig.  305,  flexion;  and  Fig.  306,  rotation  of  joint. 


had  not  been  diseased.  The  first  one  is  the  best  standing  position,  the  second 
forced  flexion  in  the  standing  position,  and  the  third  standing  on  one  limb  and 
flexing  the  limb  across  the  other  one.  These  tests  are  well  shown  in  the 
accompanying  figures  (Figs.  307-315). 

In  all  cases  where  suppuration  has  occurred,  shortening  to  a  greater  or 
less  degree  is  the  rule.  The  degree  of  ultimate  shortening  will  depend  upon 
the  position  of  the  limb,  dislocation  true  or  false,  actual  destruction  of  osseous 
tissue  by  disease  or  operation,  and  arrest  of  growth.  The  amount  of  shortening 
increases  slightly  subsequently  from  permanent  retardation  of  growth. 

By  massage  and  exercise  muscular  atrophy  may  be  diminished  but  never 
entirely  disappears.     The  appearance  of  abscess  is  significant  either  of  inefficient 


344  ORTHOPEDIC  SURGERY. 

treatment  or  of  the  advancement  of  the  disease  in  spite  of  thorough  treatment. 
In  the  former  event  it  demands  greater  care  and  vigUance,  in  the  latter  it 
betokens  a  serious  prognosis  and  a  high  mortality. 

Treatment. 

The  treatment  of  hip-joint  disease  has  in  later  years  received  much  attention 
and  been  greatly  modified.  From  the  time  when  the  remedies  employed  were 
entirely  of  a  constitutional  nature,  little  attention  being  given  to  local  measures, 
to  the  present  time,  when  complicated  mechanical  appliances  are  employed 
to  the  complete  exclusion  of  local  remedies,  many  decided  advantages  have 
been  secured  and  many  important  principles  have  been  established. 

In  conjunction  with  the  employment  of  mechanical  means  the  writer  would 
urge  the  importance,  as  adjuvants  to  a  speedy  cure,  of  improved  hygiene, 
generous  diet,  sufficient  sleep,  and  such  constitutional  medication  as  the  general 
condition  of  the  afflicted  individual  may  indicate.  In  some  instances  counter- 
irritation  and  local  applications  may  be  required  to  meet  certain  indications. 

Local  treatment  in  hip  disease  may  be  divided  into: 

1.  Conservative  or  mechanical,  and 

2.  Operative  or  surgical. 

The  conservative  or  mechanical  method  aims  to  put  the  inflamed 
joint  at  rest  by  recumbency  with  traction,  by  fixation,  or  by  traction,  the  latter 
two  being  especially  employed  as  portative  appliances. 

Recumbency  with  extension  is  a  weU-recognized  plan  of  treatment,  and 
one  employed  at  times  to  meet  certain  conditions  by  those  who  most  valiantly 
support  locomotion  with  portative  apparatus.  This  may  be  accomplished  by 
means  of  the  Buck  extension,  the  so-called  "stretcher  splint,"  or  "extension 
tray,"  the  gouttiere  de  Bonnet  or  wire  cuirass,  and  the  "portable  bed." 

The  "Buck  extension"  is  employed  as  in  the  treatment  of  fractures  of 
the  femur  and  as  described  in  all  systematic  works  upon  general  surgerv.  To 
secure  counter-extension  by  means  of  the  body-weight  the  foot  of  the  bed  should 
be  elevated.  From  one-half  to  two  bricks  or  an  equivalent  weight  should 
be  employed  to  make  extension.  A  more  elegant  extension,  known  commonly 
as  the  "Sayre  extension,"  may  be  applied  by  cutting  the  plaster  as  for  the  long 
traction  splint.  Two  strips  of  adhesive  plaster  the  length  of  the  entire  limb, 
about  four  or  five  inches  wide  at  the  upper  end,  and  one-third  the  width  at 
the  lower,  are  prepared  by  cutting  the  plaster  into  five  tails.  From  the  upper 
end  of  the  center  tail  a  piece  four  to  six  inches  long  is  cut  and  added  to  the 


_^ — -^    ^^^^ 


Fig.  307.— First  Test  Position,  Affected  Hh>.  Fig.  308.— Second  Test  Position,  Affected  Hip. 


Fig.  311. — First  Test  Position,  Unaffected  Hip.  Fig.  312. — Second  Test  Position,  Unaffected  Hip. 


Fig.  309.— Third  Test  Position,  Affected  Hip.  Fig.  310.— Fourth  Test  Position,  Affected  Hip. 


Fig.  313. — Third  Test  Position,  Unaffected  Hip  Fig.  314. — Fourth  Test  Position,  Un.^ffected  Hn>. 


HIP-JOINT  DISEASE.  349 

lower  end  to  reinforce  it.  The  two  applied  ends  are  folded  upon  themselves 
and  buckles  attached,  and  the  whole,  thus  prepared,  are  applied  to  the 
lateral  aspect  of  the  leg,  the  buckles  immediately  above  the  malleoli  and 
the  center  tails  extending  the  entire  length  of  the  limb.  The  lower  tails  are 
wound  spirally  about  the  leg,  overlapping  each  other,  the  other  two  pairs  are 
wound  spirally  about  the  thigh,  and  the  whole  is  secured  by  a  spiral  reversed 
roller  bandage  extending  from  the  ankle  to  the  perineum.  Extension  from  the 
buckles  is  made  with  a  steel  bar  about  six  inches  in  length,  perforated  in  the 
middle  for  the  extension  cord,  and  having  the  leather  straps  extending  from 
either  extremity.  The  advantage  of  such  an  apparatus  is  the  ease  with  which 
a  long  traction  splint  may  be  applied  at  one  time  and  extension  at  another. 

The  stretcher  splint  or  extension  tray  consists  of  an  oblong  frame  made 
of  bar  iron  one-fourth  by  one  inch  for  small  children,  one-fourth  by  one  and 
one-fourth  inches  for  older  children,  and  shellacked,  varnished,  or  galvanized 
to  prevent  rusting.  The  frame  is  then  covered  with  canvas,  except  a  two- 
or  three-inch  space  in  the  center  corresponding  to  the  anal  opening,  tightly 
laced  on  the  under  side.  Traction  is  made  with  adhesive  strips  in  the  usual 
way,  the  cord  from  the  center  of  the  stirrup  passing  over  a  wheel  attached  to 
an  upright  steel  piece  slid  on  the  lower  end  of  the  frame,  so  arranged  that  the 
\A-heel  may  be  elevated  or  lowered  to  make  extension  in  the  line  of  the  deformity. 
Counter-extension  is  made  by  two  perineal  straps  attached  to  the  frame  or 
to  an  arm  arching  over  the  hips  from  the  affected  side  and  iirmly  secured  to 
the  side  bar  of  the  stretcher.  These  straps  pass  through  the  central  opening 
and  upward,  to  be  attached  to  the  stretcher.  Shoulder-straps  to  prevent  rising 
may  be  added,  but  are  seldom  required.  Upon  this  stretcher  or  extension 
bed  the  child  may  be  carried  from  place  to  place. 

The  gouttiere  de  Bonnet  or  wire  cuirass  fulfils  the  same  indications — 
recumbency  and  extension — but  is  more  expensive.  The  portable  bed,  as 
constructed  by  Phelps,  possesses  all  the  excellent  qualities  of  the  wire  cuirass, 
and  has  the  advantage  of  cheapness,  being  a  plaster  and  wooden  cuirass  which 
any  practitioner  may  readily  construct.  A  board  of  three-quarters  of  an  inch 
spruce  is  cut  to  correspond  to  the  shape  of  the  child,  four  inches  longer  and 
three-quarters  of  an  inch  wider  than  the  patient.  The  child  is  then  laid  upon 
the  board  and  enveloped  with  a  plaster-of-Paris  bandage  from  the  feet  to  the 
axilla  to  a  thickness  of  three-eighths  of  an  inch.  As  the  plaster  bandages  are 
rolled  on  they  should  be  nailed  to  the  edges  of  the  board,  thus  making  the  board 
and  plaster  one.     When  the  plaster  is  set,  the  front  is  cut  away.     The  bed  is 


350  ORTHOPEDIC  SURGERY. 

then  lined,  a  front  put  on,  and  lacings  put  in,  or  the  child  can  be  held  in  place 
by  bandages.     Extension  is  made  to  the  foot-piece. 

This  furnishes  a  cheap  and  excellent  mode  of  treatment,  particularly  in 
the  more  acute  stages  of  the  disease,  and  in  it  the  child  may  be  readily  carried 
about  without  the  possibility  of  injury  to  the  affected  part. 

The  Fixation  Method.— Fixation,  as  a  principle  in  the  management 
of  hip-joint  disease,  enters  into  the  methods  of  treatment  before  described, 
but  as  an  element  in  the  employment  of  portable  splints  it  deserves  further 
notice.  Fixation  without  extension  is  the  principle  of  the  fixation  or  so-called 
English  method,  to  distinguish  it  from  splints  constructed  on  the  principle 
of  extension,  or  the  so-called  American  method. 

They  are  all  constructed  upon  a  combination  of  the  physiologic  and  fixative 
methods,  and  aim  to  immobilize  the  hip-joint  by  plaster-of-Paris  bandages, 
leather  or  metal  splints  applied  to  the  hip,  pelvis,  and  thigh,  and  the  use  of 
crutches  and  a  patten.  A  plaster-of-Paris  bandage  may  be  applied  from  the 
ankle  of  the  affected  limb  up  to  the  axilla,  encircling  the  limb,  pelvis,  and  thorax. 
As  a  temporary  measure  it  has  advantages,  particularly  if  applied  under  ether 
for  the  correction  of  deformity,  but  as  a  permanent  dressing  it  is  clumsy  and 
uncleanly.  Moreover,  it  does  not  firmly  fix  the  trunk  above  the  pelvis,  the 
possible  motion  of  the  lumbar  vertebras  interfering  with  the  fixation  of  the  hip- 
joint  through  the  movement  of  the  pelvis.  Moreover,  it  has  no  eft'ect  upon 
reflex  muscular  contraction  and  the  coincident  intra-articular  pressure,  since 
no  traction  is  applied,  and  consequently  will  not  prevent  the  destruction  of 
the  head  of  the  femur  and  perforation  of  the  acetabulum  from  absorption. 
The  usual  deformities  peculiar  to  the  disease  may  be  prevented. 

The  same  remarks  apply  to  the  fixation  leather  and  metal  splints,  which, 
not  extending  so  high  in  the  thorax  or  so  low  in  the  limb,  do  not  fix  the  joint  so 
well  as  the  plaster  dressing.  They  fulfil  certain  indications,  however,  and 
in  some  cases  accomplish  good  results,  but  as  a  mode  of  treatment  to  the  exclusion 
of  others  they  are  not  to  be  recommended.  A  very  ingenious  fixation  splint 
is  the  one  devised  by  Willard.  It  is  made  of  enameled  leather  over  a  cast, 
and  has  a  simple  joint  over  the  articulation  so  that  the  patient  can  sit  down 
with  comfort.  It  is  always  used  in  connection  with  crutches  and  a  high 
shoe,  and  is  applicable  to  a  limited  number  of  cases— those  in  which  the  in- 
flammatory symptoms  are  not  acute. 

The  most  perfect  tj^pe  of  a  pure  fixation  splint  is  that  of  Thomas,  which, 
in  his  hands,  was  undoubtedly  an  efiicient  apparatus,  as  almost  any  apparatus 


HIP- JOINT  DISEASE. 


351 


might  become,  considering  the  skill,  accuracy,  and  thoroughness  with  which 
it  was  applied. 

It  is  simple  in  construction,  and  can  be  readily  made  by  the  practitioner. 
It  consists  of  a  malleable  iron  bar  extending  from  the  lower  angle  of  the  scapula 
to  the  lower  third  of  the  leg — ^just  where  the  calf  begins.  This  should  be  one 
inch  by  one-quarter  inch  for  an  adult,  and  three-quarters  by  three-sixteenths 
for  children.  Three  strips  of  hoop  iron,  one  (the  chest  crescent)  for  the  upper 
extremity,  four  inches  less  than  the  circum- 
ference of  the  thorax,  attached  at  right  angles 
to  the  upright;  one  (the  thigh  crescent)  for 
the  thigh,  two-thirds  the  circumference  of  the 
thigh  at  its  upper  third ;  another  (the  calf  cres- 


FiG.  315. — Thomas  Hip  Splint. 


Fig.  316. — Thomas  Hip  Splint  Applied. 


cent)  for  the  calf,  one-half  the  circumference  of  the  limb  at  this  point.  The  splint, 
fitted  to  the  posterior  part  of  the  trunk  and  affected  limb,  is  held  in  position  by 
a  strap  and  buckle  attached  to  the  upper  band;  suspenders  are  used  over  the 
shoulders,  and  a  roller  bandage  firmly  applied  to  the  lumbar  portion  and  the 
limb.  A  patten  is  worn  on  the  sound  side,  high  enough  to  clear  the  foot  of 
the  diseased  limb,  and  crutches  are  employed. 

Its  proper  application  requires  skUl,  and  its  inventor  deserves  credit  for 
the  great  attention  to  detail  exhibited  in  describing  the  splint.     This  method 


352  ORTHOPEDIC  SURGERY. 

of  treatment  has  much  to  recommend  it  to  the  profession  in  general,  particularly 
in  hospital  cases  and  where  patients  cannot  secure  sufficient  personal  attention 
to  employ  a  traction  splint.  Under  these  conditions  better  results  are  attained 
by  fixation  methods  than  by  traction  appliances  improperly  used. 

As  a  fixation  splint  in  recumbent  cases  with  traction  it  is  an  excellent 
appliance.  For  the  correction  of  deformity  the  upright  is  bent  at  the  buttock, 
and  the  splint  is  applied  in  the  deformed  position,  the  curve  of  the  upright 
being  lessened  as  the  deformity  yields.  While  the  fixation  of  the  Thomas 
splint  is  not  perfect,  the  principal  objection  is  that  there  is  no  traction  to  prevent 
intra-articular  pressure  from  reflex  muscular  contraction.  My  own  observation 
leads  me  to  believe  that  abscesses  are  more  frequent,  and  this  impression  is 
confirmed  by  comparison  of  the  report  of  62  cases  of  hip  disease  observed  in 
the  practice  of  Thomas,  of  Liverpool,  by  Ridlon,  of  58  of  which  23  had  one 
or  more  abscesses,  or  39.6  per  cent.,  and  the  results  of  a  series  of  63  cases  from 
the  Boston  Children's  Hospital,  in  which  abscesses  occurred  in'^only  23  per 
cent,  of  all  cases  of  hip  disease  under  out-patient  treatment.  Since  these  reports 
represent  the  best  results  of  both  the  fixation  and  traction  methods  of  treatment 
in  the  hands  of  surgeons  of  equal  skill,  under  similar  conditions,  the  com- 
parison may  be  considered  just  and  the  result  obvious. 

When  supplemented  by  bed  traction  during  the  first  part  of  the  treatment, 
and  by  bed  traction  at  night  during  the  subsequent  part  of  the  disease,  it  forms 
a  satisfactory  form  of  treatment  in  hospital  cases. 

Fixation  versus  Ankylosis. — The  dread  of  ankylosis,  according  to 
Verneuil,  has  led  to  much  bad  surgical  practice,  but  recent  experiments  and 
discussions  have  clearly  established  the  dictum  of  Gibney,  "that  whatever 
ankylosis  occurs  in  a  joint  subjected  to  immobilization,  occurs  by  reason  not 
of  the  immobilization,  but  of  the  nature  and  intensity  of  the  inflammations 
and  of  the  inefficiency  of  the  apparatus  employed." 

Perfect  immobilization,  or  absolute  fixation,  is  almost  an  impossibility 
by  fixation  apparatus  alone.  False  ankylosis  is  due  to  contraction  of  the 
peri- articular  muscles  from  reflex  irritative  spasm.  Fixation  by  means  of  traction 
applied  early  will  relieve  muscular  spasm,  prevent  trauma  of  the  articular 
surfaces,  diminish  intra-articular  pressure,  and  permit  a  subsidence  of  the 
inflammation,  after  which  either  motion  or  fixation  may  occur  in  the  joint, 
since  ankylosis,  if  it  occurs,  depends  directly  upon  the  amount  of  disease,  and 
not  upon  either  fixation  or  traction. 

Phelps,  in  a  scries  of  carefully  conducted  experiments  upon  dogs,  concludes : 


HIP-JOINT  DISEASE. 


353 


(i)  That  a  normal  joint  will  not  become  ankylosed  by  simply  immobilizing 
it  for  five  months.  (2)  That  motion  is  not  necessary  to  preserve  the  normal 
histologic  character  of  a  joint.  (3)  That  when  a  healthy  joint  becomes  anky- 
losed or  its  natural  histologic  character  changed,  it  is  not  due  to  prolonged 
rest,  but  to  pathologic  causes.  (4)  That  immobilization  of  a  joint  in  such 
a  manner  as  to  produce  and  continue  intra-articular  pressure  will  result  in 
destruction  of  the  head  of  the  bone  and  the  socket  against  which  it  presses. 
(5)  That  atrophy  of  the  muscles  of  the  limb  will  follow  prolonged  immobili- 
zation of  a  joint. 

If,  as  he  remarks,  these  experiments  prove  that  prolonged  filiation  will 
not  produce  ankylosis  of  a  natural  joint,  that  motion  is  not  essential  for  the 
preservation  of  its  normal  function,  then  the  causes  of  ankylosis  must  depend 
upon  pathologic  conditions,  and  not  upon  prolonged  fixation. 

These  experiments  are  valuable  as  illustrating  the  effect  of  prolonged 


Fig.  317. — Instinctive  Effort  at  Traction  in  Hip  Disease. 


fixation  in  healthy  joints.  They  do  not  solve  the  problem  of  the  control  of  reflex 
muscular  spasm,  the  most  destructive  element  in  the  disease.  Traction,  with 
or  without  fixation,  will  best  control  this  muscular  spasm,  diminish  intra- 
articular pressure,  secure  rest,  and  diminish  inflammation. 

Traction  by  extension  and  counter-extension  is  the  keynote  of  correct 
surgical  treatment  in  hip-joint  disease. 

The  Traction  Method. — It  is  upon  this  principle  of  traction  in  the  line 
of  deformity  that  the  long  extension  splint,  or  the  so-called,  by  Europeans, 
American  method  of  treatment  for  hip- joint  disease,  is  established.  To  relax 
the  muscles  by  overcoming  the  muscular  spasm,  and  to  induce  fixation  and 
prevent  concussion,  are  the  objects  sought.  It  would  appear  from  recent 
experiments  that  a  distracting  force  sufficient  to  separate  the  head  of  the  bone 
from  the  acetabulum  is  neither  necessary  nor  desirable.  Experiments  upon 
the  cadaver  are  unreliable,  since  reflex  muscular  spasm,  the  most  important 

24 


354 


ORTHOPEDIC  SURGERY. 


factor,  is  absent.  Konig  and  Paschen,  upon  the  cadaver,  found  slight  separation, 
using  eight  pounds  or  more ;  while  Morosoff  was  unable  to  separate  the  surfaces 
with  less  than  sixty  pounds.  Lannelongue,  however,  by  frozen  sections  found 
ten  pounds  sufficient  to  produce  separation  in  a  well-marked  case  of  hip  disease. 
(For  a  thorough  resume  of  the  subject  of  distraction,  vide  "An  Experimental 
Study  of  Distraction  of  the  Hip-joint,"  by  E.  G.  Brackett,  "Trans.  Amer. 
Orthop.  Assoc,"  vol.  ii,  p.  207;  also  Judson,  "Growth  and  Deformity,"  1905, 

p.  88.)  Upon  anatomic  grounds  a  much  less 
weight  is  known  to  be  required  to  produce  dis- 
traction if  the  limb  be  abducted,  since  when 
the  limb  is  in  the  line  of  the  body,  or  adducted, 
the  cotyloid  ligament  surrounding  the  head 
renders  separation  almost  impossible. 

Lovett. estimated  from  an  experiment  upon 
a  healthy  boy  of  ten  years  that  the  thigh  mus- 
cles are  capable  of  exerting  a  force  of  thirty- 
six  pounds.  It  is  highly  probable  that  separa- 
tion of  joint  surfaces  in  hip  disease  is  seldom 
or  never  attained,  but  that  the  traction  force 
employed  for  a  long  time  overcomes  the  mus- 
cular spasm,  secures  fixation  and  rest  to  the 
affected  part.  The  amount  of  fixation  at  the 
hip-joint  secured  by  the  long  traction  splint 
has  been  variously  estimated,  but  the  only  ex- 
periments of  any  practical  value  are  those  of 
Lovett,  before  referred  to.  Traction  will  best 
fix  the  joint  and  fulfil  the  indications  in  the 
acute  forms  of  disease  when  the  joint  be- 
tween the  upright  and  pelvic  band  is  fixed 
by  a  screw  or  strap  of  webbing  which  will  permit  or  arrest  motion,  and  where 
two  perineal  straps  are  employed. 

Traction  Splints. — All  long  traction  splints  at  present  in  use  are  patterned 
more  or  less  after  Taylor's  modification  of  Davis'  splint,  being  commonly 
described  as  the  "Taylor  splint,"  the  "Sayre  long  splint,"  or  the  "long  traction 
splint."  The  principles  of  the  so-called  mechanical  treatment  are  founded 
upon  the  two  following  aphorisms:*     "  (i)  All  organs  while  in  a  state  of  disease 


Fig.  j;iS. — Tayloi:  ilu'  Splint. 


*  Taylor:  "Boston  Med.  and  Surg.  Jour.,"  March  6,  1S79. 


HIP-JOINT  DISEASE. 


355 


require  rest  from  the  performance  of  their  functions  in  the  direct  ratio  of  the 
amount,  quahty,  and  intensity  of  the  abnormal  movements.  (2)  What  is  rest 
for  an  organ  in  one  condition  is  not  necessarily  rest  for  it  in  another  condition ; 
that  is  to  say,  an  organ  in  a  certain  degree  of  progressive  inflammation  presents 
conditions  essentially  different  from  the  same  organ  in  the  same  relative  degree 
of  inflammation  in  the  retrogressive  stage." 

The  first  object  sought  is  to  overcome  the  muscular  contraction  by 
extension  and  counter-extension  applied  to  the  line 
of  the  deformity.  This  is  accomplished  by  means 
of  a  long  steel  bar  extending  from  the  trochanter 
to  below  the  foot,  to  which  above  is  rigidly  attached 
a  sheet-steel  pelvic  girdle  and  one  or  two  perineal 
bands,  and  which  below  is  attached  to  the  limb  by 
adhesive  plaster  straps  or  bandages.  To  more 
readily  adjust  the  appliance  to  varying  lengths  of 
legs,  as  well  as  to  apply  extension,  the  long  steel 
bar  is  provided  with  a  tube  and  sliding  racheted  bar 
moved  by  a  key  and  secured  by  a  spring  and  sliding 
catch.  The  lower  part  of  such  a  splint,  bent  at  right 
angles  to  the  long  upright  bar,  is  covered  with  a  flat 
leather  or  rubber  shoddy  shoe,  and  has  attached  a 
leather  strap  for  attachment  to  the  buckles  upon  the 
adhesive  appliance  on  the  leg.  The  pelvic  band 
may  be  rigidly  attached  to  the  long  bar,  but  is  best 
secured  by  a  bolted  screw,  which  will  permit  motion 
or  fixation.  The  perineal  straps  may  be  made  of 
military  webbing  covered  with  leather,  canton  flannel, 
silk,  or  chamois.  Pads  are  objectionable,  straps  be- 
ing more  comfortable  and  less  likely  to  chafe  or  ex- 
coriate. With  ordinary  care  as  to  cleanliness  and  the  local  application  of 
alum  and  alcohol,  two  drams  to  the  pint,  followed  by  dusting  with  talcum 
or  ordinary  toilet  powder,  little  difficulty  will  be  experienced,  and  any  reasonable 
amount  of  pressure  may  be  made  upon  the  perineum.  Should  the  parts  chafe 
or  excoriate,  acetanflid  in  unguentum  aqua  rosa  or  vaselin  will  relieve,  or,  failing 
in  that,  the  splint  may  be  removed  for  a  few  days  and  the  patient  be  confined  to 
bed,  traction  being  applied  by  a  cotton  roller  or  stockmg. 

The  long  bar  may  be  variously  modified  to  meet  indications.     The  upper 


Fig.  319. — Traction  Splint  for 
THE  Left  Leg,  seen  from 
THE  Back,  Provided  with 
Two  Perineal  B.ands  and 
AN  Abduction  Screw  (Brad- 
ford and  Lovett)._ 


356 


ORTHOPEDIC  SURGERY 


portion  may  be  attached  by  two  portions  for  convenience  in  dressing  sinuses; 
it  may  have  attachments  to  secure  the  knee  laterally,  or  antero-posteriorly, 
as  the  U-shaped  attachment  of  Judson,  for  the  purpose  of  better  fixation  of 
the  thigh;  or  it  may  be  made  stronger  or  less  flexible,  as  in  the  Judson  brace, 
and  so  twisted  upon  itself  and  tapered  that  the  weight  is  centered  near  the  upper 
part.  The  traction  straps  applied  for  the  extending  force  should  extend  beyond 
the  knee  and  well  up  the  thigh  to  avoid  undue  traction  upon  the  lateral  ligaments 
of  the  knee.     Strong  surgeon's  adhesive  plaster  is  efficient.     Maw's  moleskin 

plaster,  made  in  England,  is  the 
best,  but  Shivers's  swan's-down 
plaster,  made  in  Philadelphia, 
answers  equally  well.  They 
should  be  changed  about  every 
four  weeks,  but,  no  irritation  or 
displacement  ensuing,  they  may 
remain  on  from  three  to  four 
months.  If  chafing  occurs  be- 
neath the  dressing,  the  parts 
should  be  dusted  lightly  with 
powdered  boric  acid  when  being 
renewed .  Substitutes  for  plaster 
where  the  skin  is  extremely  sen- 
sitive, such  as  a  cloth  or  leather 
legging,  or  a  stocking  extension, 
may  be  employed,  but  all  are 
inferior. 

The  plaster  should  be  cut  as 
before  described,  and  the  roller 
bandage  applied  to  retain  them  should  be  over-seamed  its  entire  length,  or,  better, 
be  secured  by  a  narrow  strip  of  adhesive  plaster  wound  spirally  up  the  leg  and 
thigh.  In  applying  the  splint  the  pelvic  band  and  perineal  straps  should  first 
be  secured,  next  the  foot-piece  be  attached  by  the  straps  to  the  buckles; 
extension  is  then  to  be  made,  and  finally  the  knee  is  to  be  secured.  Such  a 
splint  may  be  at  once  employed  for  ambulatory  purposes,  a  shoe  with  a  sole 
sufficiently  high  to  equalize  the  length  of  the  limbs  being  worn  on  the  opposite 
limb,  but  in  acute  cases  it  is  better  for  the  patient  to  maintain  the  recumbent 
position  until  the  acute  symptoms  have  subsided,  or  to  resume  this  position 


Fig.  320. — Combined  Fixation  and  Traction  Splint 
(Lovett).  (By  permission  of  the  Trustees  of  the  Fiske 
Prize  Fund.) 


HIP-JOINT  DISEASE. 


357 


should  increased  pain  or  deformity  indicate  an  exacerbation  of  the  disease. 
Taylor's  method  of  reducing  deformity  by  placing  the  patient  upon  an  inclined 
plane,  with  conveniences  for  adapting  the  angle  to  the  amount  of  relaxation 
gained,  is  practical  and  efficient,  and  will  be  detailed  under  the  treatment  of 
deformity  following  hip  disease. 

So  applied  in  the  line  of  deformity,  the  splint  has  necessitated  certain 
modifications.  If  simply  flexion  exist,  the  long  bar  may  be  set  at  an  angle 
to  the  pelvic  girdle,  but  for  adduction  or  abduc- 
tion, Shaffer's  modification  of  the  pelvic  attach- 
ment may  be  employed.  This  consists  of  two 
parts,  joined  by  a  lateral  hinge.  The  first  part  is 
fastened  to  the  pelvic  band,  and  the  second  part  is 
attached  to  the  shaft  of  the  splint.  Through  the 
everted  lip  there  passes  a  screw,  which  operates 
through  a  button  (which  revolves  on  a  horizontal 
axis),  and  which  is  fastened  into  another  button 
(also  revolving  on  a  horizontal  pivot)  in  the  first 
part.  By  turning  the  screw,  we  can  either  ap- 
proximate the  lip  toward  the  first  part  (producing 
abduction),  or,  by  reversing  the  screw,  we  can 
separate  the  lip  from  the  first  part  and  adduct. 

The  writer  prefers  to  overcome  the  lateral 
deformity  by  extension  and  counter-extension  in 
bed  before  applying  the  splint,  or  should  deformity 
become  marked  after  the  use  of  the  splint,  to  re- 
move it  for  a  time  and  place  the  patient  in  bed  until 
the  exacerbation,  which  this  signifies,  has  subsided. 
If,  however,  such  a  course  is  inconvenient,  the 
splint  may  be  worn  and  the  patient   be  placed 

upon  crutches,  with  a  high  patten  upon  the  sound  limb.  This  was  Taylor's 
combination  method,  and  the  one  for  which  Wyeth  claimed  advantages  superior 
to  all  others.  Upon  this  principle  also  are  the  combination  splints  of  Lovett 
and  Phelps,  modified  combinations  of  the  English  Thomas  splint  with  the 
American  Taylor  splint,  both  excellent  splints  for  use  in  cases  in  which  the 
fixation  afforded  by  the  Taylor  traction  splint  is  not  sufficient.  The  latter 
possesses  many  other  excellent  qualities,  since  it  is  intended  to  prevent  every 
motion  at  the  hip-joint,  and  at  the  same  time  apply  extension  in  a  line  with 


Fig    321  — Phelps  s  Combin-vtion 
Traction  Hip  Splints 


358  ORTHOPEDIC  SURGERY. 

the  neck  of  the  femur,  but  is  a  little  heavier  and  more  unwieldy  than  the  ordinary 
Taylor  splint. 

Convalescent  Protective  Splints. — After  all  the  characteristic  signs 
have  disappeared  for  a  considerable  period  under  traction  treatment,  it  ^\\\ 
still  be  necessary  to  protect  the  limb  from  the  jar  in  vitalising,  and  as  a  precaution 
against  injury.  For  this  purpose  the  ordinary  extension  may  be  employed 
by  simply  diminishing  the  extension  and  counter-extension  until  the  shoe  rests 
nearly  or  completely  upon  the  ground.  If  it  is  desirable  to  have  a  joint  at 
the  knee,  the  convalescent  splint  of  Taylor  or  one  of  its  many  modifications 
may  be  employed.  In  the  former,  "the  lower  steel  plate  is  riveted  to  the  upright, 
but  the  upper  one  is  fastened  by  three  'keepers,'  which  enable  it  to  be  raised 
or  lowered  in  adapting  the  instrument  to  the  length  of  the  leg." 

The  use  of  crutches  as  a  means  of  protection,  the  sound  limb  being  raised 
upon  a  patten,  will  be  found  useful  in  convalescent  cases  before  abandoning 
the  splint  altogether.  Protection  will  be  necessary  from  eighteen  months 
to  two  years  after  the  complete  disappearance  of  all  the  active  symptoms,  and 
in  severe  cases  even  longer,  it  being  better  to  wear  the  splint  too  long  than  to 
suffer  relapse  from  its  too  early  removal. 

Treatment  of  Complications. 

The  complications  which  will  demand  special  treatment  are  "night-cries," 
abscesses,  and  malpositions  of  the  limb. 

Night-cries  usually  at  once  subside  under  the  use  of  traction  in  the  line 
of  deformity  and  fixation  and  the  use  of  local  anesthetics  of  mesotan  ointment, 
25  per  cent.,  baum  analgesiqiie  Bengue,  etc.  Should  these  measures  fail,  a 
large  blister  over  the  trochanter,  followed  by  hot  poultices,  with  the  internal 
use  of  potassium  bromid  and  morphin,  should  be  employed.  Salicylate  of  soda 
in  full  doses,  as  for  acute  articular  rheumatism,  has  been  highly  recommended. 
If  they  continue  unabated,  operative  means  must  be  resorted  to.  Deep  puncture 
of  the  joint  or  trephining  of  the  head  of  the  femur  offers  the  greatest  chance 
of  relief,  if  induration  or  great  fullness  of  the  capsule  can  be  recognized.  Where 
these  cannot  be  discovered,  a  formal  incision  into  the  joint,  as  an  exploratory- 
operation,  should  be  undertaken.  The  extension  weight  should  be  increased, 
and  where  excruciating  pain  is  the  principal  symptom,  and  it  is  not  relieved 
by  any  of  the  measures  suggested,  excision  will  usually  reveal  the  entire  separa- 
tion of  the  epiphyseal  cap  of  the  head  by  granulation,  without  a  drop  of 
pus  being  within  the  joint.     The  sudden  subsidence  of  night-cries  indicates 


HIP-JOINT  DISEASE.  359 

the  efficiency  of  treatment  or  the  rupture  of  the  capsule  of  the  joint  and  the 
extravasation  of  pus. 

Abscesses  in  many  cases  will  rupture  spontaneously,  but  should  they 
assume  enormous  size,  or  exhibit  a  tendency  to  burrow  to  great  distances,  they 
should  be  incised.  Small  recent  abscesses  will  sometimes  disappear  under 
the  use  of  compound  iodin  ointment  and  pressure.  Aspiration  is  usually 
unsatisfactory,  and  the  subsequent  injection  of  antiseptic  solutions  is  not 
unattended  with  danger,  and  is  not  to  be  recommended. 

Some  orthopedic  surgeons  believe  in  the  spontaneous  absorption  or  rupture 
of  abscesses,  urging  the  danger  of  septic  or  tubercular  infection  for  their  fear 
of  interfering. 

My  own  opinion  is  that  if  they  are  enlarging  rapidly,  or  tending  to  spread, 
they  should  be  evacuated  at  once  under  antiseptic  precautions  by  incision. 
The  cavity  should  be  entirely  washed  out  by,  first,  a  continuous  flow  of  bichlorid 
solution  and  then  sterile  water,  it  should  be  thoroughly  rubbed  with  gauze 
pads  or  cureted,  and  drainage  should  be  inserted,  and  one  or  two  drams  of 
iodoform  emulsion  be  injected,  and  the  whole  covered  by  a  full,  dry,  sterile 
dressing.  If  the  abscess  is  to  be  evacuated,  it  should  be  thoroughly  performed; 
or  if  a  simple  incision  is  used,  care  should  be  taken  to  avoid  pressure  upon 
the  part. 

The  influence  of  incision  and  drainage  upon  the  mortality  of  hip  disease 
is  shown  in  the  statistics  of  Marsh  at  the  Alexandra  Hospital.  Before  the 
introduction  of  this  method  the  mortality  in  suppuration  cases  was  30.4  per 
cent.,  and  in  non-suppurating  cases  was  7  per  cent.;  since  incision  and  drainage 
have  been  used  as  a  routine  method  in  614  cases,  the  mortality  was  only  6  per 
cent. 

In  opening  an  abscess  an  exploration  of  the  joint  cavity,  if  accessible, 
may,  under  aseptic  precautions,  be  made. 

In  all  instances  in  operating  upon  an  abscess  the  surgeon  should  be  prepared 
to  remove  sequestra  or  to  proceed  with  an  erasion  or  excision  should  the  exigencies 
of  the  case  demand  it. 

The  Treatment  of  Sinuses. — The  treatment  of  sinuses  following  tuber- 
culous abscesses  is  the  bete  noire  of  orthopedic  surgery  at  the  present  time. 

If  the  rubber  drainage-tubes  are  not  allowed  to  remain  in  too  long,  and 
if  the  packing  is  diminished  as  quickly  as  possible,  the  sinuses  will  more 
frequently  close  than  if  these  points  are  omitted.  The  closure  of  the  sinuses 
may  often  be  hastened  by  curetage  and  by  the  use  of  pure  iodin  applied  to 


360 


ORTHOPEDIC  SURGERY. 


the  walls  by  means  of  an  applicator.  The  sinuses  should  not  be  closed  as 
long  as  there  is  any  necrosed  tissue  at  the  bottom  of  the  wound,  and  granulation 
should  be  encouraged  from  the  bottom  of  the  wound. 

The  closure  of  the  sinuses  following  tuberculous  arthritis  is  frequently 
followed  by  disease  elsewhere,  and  this  has  led  to  the  belief  among  the  laity  that 
the  closure  of  sinuses  is  not  a  proper  method  of  treatment.  Not  infrequently 
the  sinus  closes  spontaneously  because  of  the  occurrence  of  disease  elsewhere. 
If  the  necrosed  tissue  has  been  properly  removed  there  will  be  no  danger  in  the 
healing  of  the  sinuses. 

Deformity. — The  correction  of  the  malpositions  of  the  thigh  incidental 
to  the  disease  has  already  been  given.  Recumbency,  with  continued  extension, 
will  often  accomplish  correction,  even  in  severe  grades  of  fibrous  ankylosis. 

In  bony  ankylosis,  as  in  fibrous 
ankylosis,  where  mechanical 
means  have  failed  operative 
measures  should  be  employed. 
These  include  multiple 
myotomy  and  tenotomy,  brise- 
ment  force,  osteoclasis,  and 
osteotomy.  These  forcible 
measures  should  not  be  used 
in  suppurating  cases  until 
one  year  has  elapsed  after 
the  closure  of  all  sinuses,  lest  an  active  process  be  re-established. 

Multiple  myotomy  and  tenotomy.  The  contracted  structures  which 
wUl  require  division  are  the  tensor  vaginae  femoris  muscle,  the  fascia  lata,  and 
the  intermuscular  ligament  between  the  rectus  femoris  and  tensor  vaginte 
femoris.  These  can  be  divided  subcutaneously  in  the  majority  of  cases;  but, 
if  the  muscular  contraction  be  more  extensive,  an  open  incision  under  antiseptic 
precautions  should  be  performed  after  the  V-shaped  method  of  Billroth.  This 
would  prevent  the  injury  of  large  blood-vessels  or  nerves,  but  would  not  other- 
wise facilitate  the  correction  of  the  deformity,  since  the  skin  is  unimportant 
in  maintaining  the  contraction.  In  rare  cases  the  psoas  and  iliacus  may  require 
division.  This  should  always  be  performed  through  an  open  incision  on 
account  of  the  immediate  proximity  of  the  femoral  artery  and  its  branches, 
although  a  successful  case  of  subcutaneous  section  has  been  recorded  by  Abbe. 
After  multiple  tenotomy  the  limb   should   be   brought   into  a  corrected 


Fig.  322. — Appliance  for  Elevating  or  Addtjcting  Limb. 


HIP-JOINT  DISEASE.  361 

position,  manual  force  being  employed  if  necessary,  and  retained  either  by 
plaster-of-Paris  dressing  or  preferably  by  weight-extension.  If  fracture  of 
the  surgical  neck  occur  before  the  deformity  yields  to  the  manual  force,  it  does 
not  complicate  the  case,  since  the  deformity  may  then  be  corrected  and  the 
fracture  be  dressed  subsequently  as  after  mechanical  osteoclasis. 

Brisement  force.  In  forcible  manual  correction  there  is  always  some 
risk  of  the  manipulations  lighting  up  an  active  process  in  an  old  quiescent 
tuberculous  deposit,  in  true  bony  ankylosis,  and  osteoclasis  or  osteotomy  is 
therefore  preferred.  If,  however,  the  ankylosis  be  of  the  false  variety,  as  shown 
by  the  skiagraph,  forcible  measures  may  be  used.  Mechanical  osteoclasis 
for  the  correction  of  hip  deformity  lacks  precision,  and  has  of  late  been  aban- 
doned for  the  more  exact  and,  under  the  present  antiseptic  measures,  equally 
safe  operation  of  osteotomy.     • 

Osteotomy.  Under  this  head  are  included  several  operations,  all  of 
which  aim  at  a  correction  of  the  bony  deformity,  with  or  without  a  movable 
joint. 

To  Barton,  of  Philadelphia,  in  1826,  belongs  the  credit  of  first  successfully 
correcting  osseous  hip  ankylosis  by  osteotomy.  This  operation  consisted  of  a 
linear  section  through  the  femur  between  the  trochanters. 

Attempts  have  been  made  at  various  times  to  produce  artificial  joints, 
thus:  Rodgers,  of  New  York,  in  1830  modified  the  operation  by  removing 
from  between  the  trochanters  a  disk-shaped  piece  of  bone.  Sayre  still  further 
modified  the  operation  by  removing  a  segment  of  bone  from  the  same  situation, 
the  upper  section  being  semicircular,  with  its  concavity  downward,  and  the 
upper  end  of  the  lower  fragment  being  rounded  off  in  imitation  of  a  ball-and- 
socket  joint.  These  attempts  usually  result  in  failure,  and  I  have  abandoned 
them. 

The  attempt  to  produce  artificial  joints  has  been  revived  by  Murphy.* 
Utilizing  the  efforts  of  Verneuil,  Helfrich,  and  Cramer,  and  as  a  result  of 
experimental  work,  he  has  re-established  the  function  of  joints  by  interposing 
fascias  between  the  ends  of  bones.  The  interposed  material  must  contain 
considerable  quantities  of  fatty  tissue,  which,  being  subjected  to  pressure, 
forms  the  hygroma  or  lining  membrane  of  the  joints. 

The  same  idea  of  interposing  foreign  materials  to  prevent  union  had 
previously  been  employed  by  Chlumsky,  who  used  plates  of  celluloid,  silver, 

*  "Jour.  Am.  Med.  Assoc,"  May  20,  1905. 


362  ORTHOPEDIC  SURGERY. 

zinc,  and  rubber,  layers  of  collodion,  cambric,  etc.,  none  of  which  ^Yere  satis- 
factory; he  also  partially  failed  with  the  use  of  absorbable  materials,  such 
as  magnesia,  ivory,  and  decalcified  bone. 


Fig.  323. — Bilateral  Ankylosis  in  which  Attempt  to  Produce  Artificial  Joint  Failed. 

Gluck  has  utilized  a  cutaneous  wedge  in  ankylosis  of  the  mandible. 

The  first  portion  of  the  operation  of  Murphy  was  for  ankylosis  of  the  hip 
due  to  purulent  arthritis,  and  consisted  of  a  sequestrotomy ;  the  second  portion 
was  a  curetment;    the  third  operation  was  through  the  abdominal  cavity  to 


HIP-JOINT  DISEASE. 


363 


•Aftdn^ 


reach  the  acetabulum,  the  necrotic  head  being  removed.  The  fourth  operation 
was  for  complete  bony  ankylosis;  through  a  large  U-shaped  incision  the 
trochanter  was  exposed  and  divided,  the  femur  was  separated  from  the 
acetabulum  by  a  curved  chisel,  a  portion  of  the  fascia  lata  was  interposed, 
and  the  trochanter  united  with  wire  sutures.  The  result  was  20  per  cent, 
rotation  and  from  20  to  30  per  cent,  of  flexion  and  extension  with  i-|  inches 
shortening.  This  successful  case  reopens  the  entire  subject  of  the  making 
of  artificial  joints  after  ankylosis,  but  as  yet  no  successful  case  for  true  ankylosis 
following  hip  disease  has 
been  recorded. 

Adams,  in  1869,  di- 
vided the  neck  of  the  femur 
through  a  small  wound. 
Gant,  in  1872,  introduced 
his  infra-trochanteric  oper- 
ation, dividing  with  a  saw 
the  femur  below  the  lesser 
trochanter.  Volkmann,  in 
1873,  removed  a  wedge- 
shaped  piece  from  the  outer 
side  of  the  greater  trochan- 
ter of  the  femur,  breaking 
the  rest;  subsequently  sub- 
stituting an  excision  of  the 
joint  with  a  chisel  and  a 
gouge,  first  performing  a 
regular  linear  osteotomy. 

Gant's  operation  has 
been  modified  by  Maunder  by  dividing  the  femur  below  the  lesser  tro- 
chanter with  chisels  instead  of  the  saw,  and  Macewen's  osteotomes  have 
also  been  successfully  employed  by  a  number  of  surgeons,  including  the 
writer.  Of  the  various  methods  it  may  be  said  that  false  joints  are  of 
doubtful  utility  if  obtained,  besides  increasing  the  danger  of  the  operations 
— the  mobility  of  the  pelvis  compensating  for  the  loss  of  a  movable  articu- 
lation. The  operations,  therefore,  of  Adams  and  Gant  (modified)  are  to 
be  preferred  in  suitable  cases,  the  former  being  employed  where  the 
ankylosis    has    resulted    from  acute    traumatic    inflammation  and  the  neck 


Diagram  of  Different   Forms  of  Osteotomy  for 
Ankylosis  of  Hip. 


364  ORTHOPEDIC  SURGERY. 

remains  long  and  intact,  and  the  latter  in  all  other  cases  of  bony  ankylosis 
of  the  hip-joint. 

The  application  of  the  operation  of  division  of  the  neck  of  the  bone  is 
necessarily  limited,  and  Adams  considers  most  favorable  for  operation:  (i) 
Cases  of  rheumatic  ankylosis,  because  in  rheumatism  no  destruction  of  the 
bone  exists,  and  the  head  and  neck  of  the  bone  ahvays  remain  of  their  full 
natural  size.  (2)  Cases  of  ankylosis  after  pyemic  inflammation,  most  especially 
in  its  subacute  form,  from  which  the  patient  often  recovers;  in  these  cases 
destruction  of  the  bone  rarely,  if  ever,  exists,  the  cartilages  only  being  more 
or  less  destroyed.  (3)  Cases  of  ankylosis  after  traumatic  inflammation  of 
the  joints,  in  which  little  or  no  destruction  of  the  bone  occurs.  (4)  The  most 
unfavorable  cases  for  operation  are  those  which  occur  in  tuberculous  subjects, 
where  destruction  of  the  head  and  neck  of  the  femur  has  taken  place. 

The  object  sought  in  either  operation  is  the  correction  of  the  deformity 
by  more  or  less  firm  fibrous  union.  Adams's  operation,  from  the  destructive 
character  of  hip-joint  disease,  is  inapplicable  in  most  cases  of  this  nature. 

The  fact  that  section  of  the  femur  below  the  lesser  trochanter,  in  addition 
to  the  advantages  previously  mentioned,  gives  better  results  in  correcting  the 
deformity  and  in  lessening  the  chances  of  recurrence,  is  explained  by 
the  contraction  of  the  psoas  magnus  and  iliacus  internus  muscles  inserted  into 
the  lesser  trochanter.  When  the  section  is  made  below  this  insertion  these 
muscles  remain  attached  to  the  upper  fragment,  and  do  not,  therefore,  interfere 
with  the  straightening  of  the  thigh.  The  section  should  be  made  as  close  as 
possible  to  the  lesser  trochanter,  for  the  shorter  the  upper  fragment  the  less 
perceptible  will  be  the  resulting  angle  of  union,  and  the  more  natural  the  appear- 
ance of  the  limb. 

Adams's  operation  is  thus  performed:  The  parts  having  been  sterilized, 
a  narrow,  straight  bistoury,  or  a  special  tenotome  with  a  very  long  rounded 
or  blunt  portion  and  a  cutting  surface  a  little  over  an  inch  long,  is  entered  a 
little  above  and  in  front  of  the  great  trochanter,  and  carried  straight  downward 
and  backward  to  the  neck  of  the  femur,  dividing  the  muscles  and  incising  the 
capsule  freely.  The  knife  is  then  withdrawn,  the  narrow,  firm,  pistol-handled 
saw  is  introduced,  and  the  neck  divided.  If,  after  the  neck  be  severed,  the 
rectus,  tensor  vaginse  femoris,  adductor  longus,  or  sartorius  tendons  resist 
correction  they  should  be  divided  with  the  tenotome.  Aseptic  precautions 
are  essential,  and  recumbent  extension  should  be  maintained  for  five  or  six 
weeks. 


HIP- JOINT  DISEASE. 


365 


Gant's  operation,  as  modified  by  Maunder,  is  thus  performed:  The 
parts  having  been  sterilized,  and  a  marble  slab  or  large  sand-bag  having  been 
placed  between  the  thighs  and  high  up  as  the  perineum  vs^ill  allow,  a  sharp- 
pointed,  narrow,  straight  bistoury  is  entered  just  below  the  great  trochanter 


Fig.  325. — Gant's  Subtrochanteric  Osteotomy 
FOR  Ankylosis  following  Hip-joint  Disease, 
BEFORE  Operation. 


Fig.  326. — Same,  after  Operation. 


upon  the  outer  aspect  of  the  thigh,  and  carried  directly  to  the  bone,  completely 
incising  the  soft  part.  It  is  withdrawn,  and  the  osteotome  introduced  with 
its  blade  in  the  direction  of  the  long  axis  of  the  femur,  and  turned  at  right  angles 
as  it  reaches  the  bone.  The  osteotome  is  then  driven  with  sharp  blows  until 
the  spongy  structure  of  the  bone  is  divided,  when  the  instrument  is  to  be 


366  ORTHOPEDIC  SURGERY. 

withdrawn,  and  fracture  completed  with  but  little  force.  The  limb  is  then 
brought  straight,  tenotomy  being  performed,  if  necessary,  upon  the  resisting 
structures.  A  sterile  pad  and  a  weight-extension  complete  the  dressing.  In 
children,  and  whenever  practicable,  it  is  best  to  inclose  the  leg,  thigh,  and  trunk 
in  a  plaster-of-Paris  dressing.  Should  the  limb  be  shorter  than  its  fellow, 
provision  may  be  made  for  this  for  abducting  the  limb  sufficiently  to  compensate 
for  the  subsequent  obliquity  of  the  pelvis  after  recovery.  The  permanent 
shortening  may  be  relieved  by  the  use  of  a  high  shoe  or  patten,  or  one  of  the 
special  apparatus  designed  for  this  purpose. 

The  statistics  of  these  two  operations  are  at  present  unreliable,  but  under 
strict  antiseptic  methods  these  operations  are  the  most  satisfactory  in  surgery, 
and  the  risks  as  regards  suppuration,  limb,  or  life  are  no  greater  than  in  simple 
fracture  of  these  portions  of  the  femur. 

Operative  Treatment. 

So  efficient  is  conservative  mechanical  treatment  in  the  management  of 
this  disease  that  operative  treatment  is  seldom  or  never  required  in  private 
practice  where  the  patient  has  been  under  complete  control  of  the  surgeon 
from  the  inception  of  the  disease.  In  hospital  practice,  and  in  neglected  and 
badly  treated  cases,  operative  measures  become  absolutely  necessary  for  the 
salvation  of  life  or  limb.  The  proper  selection  of  cases  for  operation  is  most 
difficult,  and  will  depend  much  upon  the  diagnostic  skill  of  the  surgeon.  The 
use  of  skiagraphs  render  the  diagnosis  more  accurate.  Operative  treatment 
should  always  be  preceded  by  thorough  mechanical  treatment.  There  are 
conditions  in  which  the  propriety  of  operative  interference  cannot  be  questioned, 
and  in  albuminuric  cases  from  prolonged  suppuration,  or  where  from  great 
destruction  of  tissue  or  exquisite  prolonged  pain,  as  in  acute  cases  of  caries 
sicca  without  suppuration,  dissolution  is  imminent.  Other  cases  will  depend 
almost  entirely  upon  the  surroundings  and  social  condition  of  the  individual, 
since  in  private  cases  in  whom  mechanical  treatment  is  thoroughly  and 
intelligently  carried  out,  the  necessity  for  operation  is  exceedingly  rare. 

The  operative  measures  employed  in  the  treatment  of  hip  disease 
include : 

1.  Aspiration  of  joint  fluid. 

2.  Trephining  and  drilling. 

3.  Incision  of  joint. 

4.  Exploratory  incision,  erasion,  and  drainage. 


HIP-JOINT  DISEASE.  367 

5.  Excision. 

6.  Amputation. 

Aspiration  of  Joint  Fluid. — The  removal  by  aspiration  of  joint  fluid 
in  cases  of  induration  and  great  distention  of  the  capsule  is  of  great  utility, 
especially  in  acute  cases.  In  traumatic  synovitis,  which  may  speedily  degenerate 
into  a  tuberculous  arthritis,  aspiration  may  at  once  arrest  the  disease.  If  the 
parts,  hands,  and  instrument  be  sterilized,  no  harm  can  possibly  result  from 
aspiration.  The  puncture  may  be  made  anteriorly  a  little  above  and  in  front 
of  the  great  trochanter,  but  is  preferably  made  posteriorly  behind  the  great 
trochanter.  In  removing  the  aspirator  care  should  be  taken  to  prevent  the 
ingress  of  air,  and  the  wound  should  be  sealed  with  iodoform  collodion  and 
cotton  or  a  sterile  dressing.  Rest  and  extension  in  the  line  of  deformity  should 
be  subsequently  continued  until  all  active  symptoms  have  subsided.  The 
injection  of  germicidal  solutions  is  not  recommended  and  the  use  of  iodoform 
emulsion,  useful  in  smaller  joints,  is  not  satisfactory  here,  since  it  acts  as  a 
foreign  body  and  has  to  be  subsequently  removed. 

Trephining  and  Drilling. — As  proposed  and  performed  by  Fitzpatrick, 
the  operation  consists  in  trephining  into  the  great  trochanter  a  short  distance 
and  attempting  to  destroy  the  diseased  area  by  inserting  a  stick  of  potassa 
cum  cake.  As  revived  by  Stoker  and  performed  by  Lovett  and  others,  it  consists 
in  trephining  with  a  small  trephine  from  the  outer  surface  of  the  great  trochanter 
in  the  direction  of  the  axis  of  the  neck  as  deeply  as  possible  without  injury 
to  the  joint,  and  subsequently  with  a  curet  evacuating  the  diseased  focus;  a 
drainage-tube  and  aseptic  pad  complete  the  dressing.  Others  employ  a  drill 
or  gouge  in  the  same  manner.  The  operation  is  a  recognized  and  valuable  one 
where  the  disease  is  confined  to  the  epiphyseal  juncture  of  the  upper  extremity 
of  the  femur,  but  even  these  would  appear  to  the  writer  to  be  better  treated 
by  exploratory  incision  and  erasion,  presently  to  be  described. 

Incision  of  the  Joint. — A  straight  posterior  incision  behind  the  great 
trochanter  is  of  great  service  where  in  acute  cases  aspiration  in  the  same  locality 
has  failed  to  relieve  the  capsular  distention  and  acute  pain.  It  has  also  the 
advantage  of  permitting  the  removal  of  diseased  and  softened  bone  by  means 
of  a  curet.  A  narrow  straight  bistoury  is  entered  behind  the  great  trochanter 
and  thrust  directly  to  the  joint,  incising  the  capsule.  The  benefit,  if  any,  is 
at  once  experienced.  As  a  simple  incision  it  has  no  particular  advantage  over 
aspiration,  except  cases  in  which  the  joint  contents  are  too  thick  to  pass  through 
the  aspirator. 


368  ORTHOPEDIC  SURGERY. 

Exploratory  Incision,  Erasion,  and  Drainage. — As  performed  by 
Willard,  the  operation  consists  in  making  an  incision  o^•er  the  most  de- 
pendent portion  of  the  abscess,  avoiding  the  large  vessels  and  nerves,  and  also 
paying  attention  to  the  integrity  of  the  muscular  fibers  as  far  as  possible, 
or  following  sinuses  if  they  exist.  By  irrigation  with  hot  sublimate  solution 
(i  :  2000)  a  protective  layer  of  coagulated  albumen  is  formed  upon  the  freshly  cut 
surface  to  prevent  tuberculous  infection.  The  opening  into  the  joint  is  enlarged 
and  with  a  hollow-handled  sharp  spoon  every  portion  of  diseased  tissue  that 
can  be  reached  is  cut  away.  I  have  modified  this  by  cauterizing  the  cut  surfaces 
of  the  incision  with  the  Paquelin  cautery,  before  cureting,  in  order  to  prevent 
absorption.  The  spoon  Willard  employs  is  a  sharp  Barker  spoon  with  a 
bulky  handle  tunneled  longitudinally  with  a  large  bore  so  as  to  allow  a  free 
flow  of  water  from  the  rubber  supply- tube.  The  roughened  ends  of  bone 
are  sawed  oft"  or  gnawed  by  strong  rongeurs,  and  diseased  fragments  of  soft 
tissue  are  removed  with  knife  and  scissors.  A  rubber  drainage-tube  is  inserted 
and  the  wound  is  packed  with  sterile  gauze.  A  large  aseptic  dressing  and 
compress  cover  the  wound.  The  operation  as  thus  performed  substitutes 
in  many  cases  the  graver  operation  of  excision,  and  where  the  bone  destruction 
has  been  small  it  offers  great  advantages  over  the  latter  operation. 

Rest,  weight-extension,  and  fixation  are  essential  to  a  cure,  and  should 
be  continued  until  every  sign  of  the  disease  has  disappeared. 

Excision. — In  cases  requiring  operative  interference  where  exploratory 
incision  reveals  areas  of  diseased  bone  too  extensive  to  be  removed  by  erasion, 
excision  will  be  required.  In  well-selected  cases  it  is  an  operation  of  great 
value,  and  one  which,  since  its  introduction  fifty  years  ago  by  Sir  W^Uliam  Fer- 
gusson  and  his  school,  has  had  an  important  effect  in  diminishing  the  number 
of  amputations  for  joint  disease.  It  must  not,  however,  be  forgotten  that 
the  operation  of  excision  is,  in  every  region  of  the  body,  at  least  as  fatal  as  the 
corresponding  amputation.  It  should  not  become  a  routine  practice  in  bad 
cases,  nor  should  it  in  selected  cases  be  considered  as  a  dernier  ressort. 

Excision  of  the  hip-joint  for  tubercular  arthritis  should  be  thorough  when 
it  is  required;  and  there  are  two  points  which  should  be  insisted  upon  in  all 
excisions:  first,  the  preservation  of  the  body-heat,  and,  secondly,  rapidity 
of  operation.  The  electric  mattress  has  proved  very  valuable  in  preventing 
the  loss  of  body-heat,  and  has  also  prevented  shock  in  the  majority  of  cases. 
There  are  few  operations  in  surgery  in  which  the  shock  is  more  profound  than  in 
excision  of  the  hip. 


HIP-JOINT  DISEASE.  369 

Rapidity  of  operation  is  quite  as  important  in  orthopedic  surgery  as  in 
acute  surgery,  although  it  requires  more  experience  and  greater  skill  to  perform 
these  difficult  operations  rapidly.  The  watchwords  in  operations  of  this  kind 
should  be  "Quickly,  safely,  and  well."  Much  delay  in  operations  may  be 
avoided  by  planning  well  before  beginning  to  operate,  by  having  a  good  corps 
of  assistants,  and  by  rapid  manipulation  at  the  time  of  the  operation. 

Excision  of  the  hip-joint.  Of  the  many  incisions  recommended,  the 
lateral  or  postero-lateral  is  the  most  satisfactory.  A  straight  or  slightly  curved 
incision  is  made,  beginning  at  a  point  one  inch  above  and  behind  the  trochanter, 
and  passing  downward  and  slightly  backward  curving  behind  and  around 
the  trochanter  for  a  distance  of  from  four  to  six  inches,  including  the  skin  and 
fascias.  The  separation  of  the  fibers  of  the  gluteus  maximus  exposes  the 
capsule,  the  division  of  which  should  be  cautiously  made  with  a  probe-pointed 
bistoury.  When  practicable,  the  periosteum  should  be  stripped  back,  and 
preserved  as  much  as  possible.  The  head  of  the  femur,  or  what  remains  of  it, 
should  be  pushed  out  of  the  acetabulum  by  rotating  and  adducting  the  limb, 
and  the  femur  should  be  removed  with  cutting  forceps  or  saw  immediately 
below  the  great  trochanter. 

If  the  acetabulum  be  diseased,  it  should  be  thoroughly  cureted  and  all 
necrosed  fragments  should  be  removed  with  gouge  forceps  or  thumb  gouge. 
The  removal  of  the  entire  acetabulum  is  not  recommended  here. 

All  sinuses  should  be  thoroughly  cureted,  and  where  possible  they  may 
be  used  for  the  primary  incision.  Drainage  should  be  provided  posteriorly. 
Drainage-tubes  should  be  inserted  and  the  wound  should  be  irrigated  with 
saline  solution  and  packed  with  sterile  gauze.  The  limb  should  be  fixed  in 
a  plaster  dressing  or  the  patient  may  be  fixed  in  a  frame  and  bed  traction  be 
applied. 

An  anterior  incision,  as  recommended  by  Barker,  is  sometimes  satisfactory 
where  the  disease  is  confined  to  the  head  and  neck  of  the  femur.  It  begins 
just  below  the  anterior  spine,  and  is  carried  downward  in  the  longitudinal 
axis  of  the  femur,  for  four  inches.  The  capsule  should  be  divided  and  the 
neck  of  the  femur  should  be  severed  with  an  osteotome  or  Adams  saw.  Posterior 
drainage  is  usually  required.  The  after-treatment  is  the  same  as  for  the  lateral 
incision. 

It  should  be  remembered  that  excision  is  less  satisfactory  in  the  hip  than 
in  the  knee,  anlde,  or  elbow,  because  of  the  difficulty  of  removing  entirely 
the  disease  in  the  acetabulum.     One    exception   requires    explanation:    the 


370  ■  ORTHOPEDIC  SURGERY. 

performance  of  excision  upon  a  patient  suffering  from  amyloid  disease  of  the 
kidneys.  Though  considered  a  contraindication  by  most  systematic  writers 
upon  surgery,  when  indications  of  commencing  amyloid  disease  make  their 
appearance,  excision  is  almost  imperative  to  check  the  drain  upon  the  con- 
stitution, notwithstanding  the  immediate  risks  of  the  operation,  and  may  be 
undertaken  with  strong  hope  of  arresting  the  kidney  disease. 

The  views  of  accepted  authorities  upon  the  indications  for  excision  are 
contradictory,  some  considering  it  a  last  resort,  others  employing  it  as  an  ac- 
cepted method  of  treatment  in  selected  cases,  while  still  others  resort  to  the 
operation  in  all  cases  once  suppuration  has  occurred. 

These  contradictory  opinions  can  only  be  reconciled  by  considering  the 
circumstances  under  which  such  opinions  were  formed,  the  character  and 
surroundings  of  the  patients,  the  facilities  for  thorough  conservative  treatment, 
etc.  Such  a  comparison  is  obviously  impracticable  here.  In  general,  it  may 
be  said  that  careful  conservative  treatment  should  always  be  carried  out  for  a 
long  time;  that  where  required  early  excisions  are  preferable  to  late  operations, 
particularly  in  hospital  and  dispensary  patients,  where  continuous  conservative 
treatment  is  impracticable;  that  whereas  the  time  required  for  treatment  by 
excision  is  shorter  than  by  conservative  methods,  the  mortality  is  higher  and 
the  resulting  limb  less  useful. 

The  ultimate  results  of  excision  are  well  shown  in  Wright's  second  series 
of  loo  cases  performed  since  the  introduction  of  the  antiseptic  method.  These 
were : 

17  soundly  healed, 

57  unhealed, 

13  dead, 

5  dying  or  going  down-hill, 

2  in  bad  condition, 

I  might  need  amputation, 

4  amputated, 

I  recent  case  doinsc  well. 


The  ultimate  results  are  not  as  satisfactory;  thus,  Konig  in  21  excisions  lost 
47.6  per  cent,  from  tuberculosis  in  four  years.  Where  patients  ultimately 
recover,  the  functional  results  are  often  excellent,  a  good  movable  joint  being 
sometimes  secured  upon  which  the  individual  can  dance  or  skate. 

The  writer  firmly  believes  that  where  cases  are  treated  by  conservative 


HIP-JOINT  DISEASE. 


371 


methods  from  the  incipiency  of  the  disease,  operative  treatment  will  be  only 
exceptionally  required,  and  that  exploratory  incision,  erasion,  and  drainage 
should  have  the  precedence  over  excision  in  all  cases  where  it  is  possible  to 
employ  the  more  conservative  operation. 

Amputation. — After  the  introduction  of  excision,  amputation  for  hip 
disease  for  a  time  fell  into  disuse.  Since,  however, 
there  has  been  a  tendency  to  revive  amputation  in 
selected  cases,  the  question  of  its  indications,  its 
mortality,  etc.,  require  consideration.  It  is  indi- 
cated where  the  femur  is  so  extensively  necrosed 
that  excision  would  not  entirely  remove  all  the 
disease,  and  in  descending  osteomyelitis.  It  is  not 
indicated  where  caries  of  the  pelvis  is  so  extensive 
that  removal  of  the  limb  would  be  of  little  service 
except  in  arresting  the  drain  upon  the  constitution, 
nor  does  the  writer  believe  it  indicated  in  amyloid 
disease,  where  excision  is  all  that  is  required  to  check 
suppuration  and  all  the  shock  such  patients  can  bear, 
nor  is  it  justifiable  where  the  patient  is  moribund. 
Where  extensive  pelvic  disease  coexists  with  disease 
of  the  shaft  of  the  femur,  it  may  be  performed  pri- 
marily before,  or  subsequently  to  excision,  but  it 
is  most  suitable  in  cases  of  extensive  disease  of  the 
shaft  of  the  femur,  without  involvement  of  the 
pelvis.  A  successful  case  is  illustrated  here 
through  the  courtesy  of  Dr.  W.  P.  Bolles,  of 
Boston,  who  performed  the  operation.  In  adults 
excision  is  less  satisfactory  than  in  children,  and, 
according  to  Wright,  "amputation  should  always 
take  the  place  of  excision  after  puberty." 

The    mortality    of    amputation     at    the    hip- 
joint  is    not   so    great    after    hip    disease   as    for 

injury  or  other  disease.  Ashhurst  has  collected  34  cases  of  primary 
and  31  of  consecutive  (i.  e.,  after  excision)  amputations,  with  19  deaths — a 
mortality,  rejecting  5  cases  in  which  the  result  was  undetermined,  of  32  per  cent. 
In  amputation  for  hip  disease,  then,  according  to  Ashhurst's  table,  the  mortality 
was  19  deaths  in  60  cases,  or  27  per  cent.,  whereas  in  the  more  recent  table 


Fig.  327. — Photograph  of 
Case  showing  Good  Re- 
sult AFTER  Excision  of 
THE  Hip-joint  for  Hip- 
joint  Disease. 


372  ORTHOPEDIC  SURGERY. 

collected  by  Bradford  and  Lovett  it  was  but  3  deaths  in  22  cases,  or  14  per 
cent.,  thus  confirming  the  statement  of  Wright  that  "amputation  at  the  hip, 
performed  with  due  precautions  as  to  hemorrhage  and  shock,  and  special  care 
during  the  first  twenty-four  hours,  is  not  a  very  fatal  operation  in  children." 
In  7  amputations  performed  by  Wright,  in  6  of  which  excision  had  been 
previously  performed,  6  recovered  well  from  the  operation,  and  i  died  from 
hemorrhage. 

More  recently  Wyeth*  reported  the  mortality  as  having  been  reduced 
to  II  deaths  in  85  cases,  or  15.29  per  cent. 

The  absolute  control  of  hemorrhage,  or  the  so-called  "bloodless  amputa- 
tions," especially  the  pins  of  Wyeth,  are  of  the  greatest  service  here,  and  the 
Furneaux- Jordan  method  of  amputation  possesses  certain  advantages;  that  is, 
an  amputation  of  the  upper  third  of  the  thigh  and  removal  of  the  femur  through 
a  lateral  incision.  For  the  various  methods  of  operating  and  the  best  means  of 
controlling  hemorrhage  the  reader  is  referred  to  works  upon  general  surgery. 

In  conclusion,  amputation  at  the  hip-joint  for  hip  disease  may  be  considered 
as  the  very  last  resort,  to  be  employed  only  when  the  disease  in  the  femur  is 
too  extensive  to  be  removed  by  resection,  contraindicated  by  extensive  amyloid 
disease  or  a  fatal  asthenic  condition  of  the  patient. 

The  treatment  of  double  hip  disease.  Since  the  hips  are  seldom 
affected  at  the  same  time,  the  treatment  of  the  disease  in  both  hips  does  not 
differ  greatly  from  the  treatment  in  one  hip. 

Recumbency  must  be  continued  longer,  greater  care  must  be  used  to  prevent 
deformity;  it  is  also  important,  if  possible,  to  avoid  complete  bony  ankylosis 
in  both  sides,  and  for  this  reason  forcible  and  more  persistent  attempts  may 
be  undertaken  to  break  up  the  adhesions  earlier.  If  bony  ankylosis  occur, 
fuU  extension  is  a  more  satisfactory  position  than  flexion.  If  bony  ankylosis 
occur  in  flexion,  it  should  be  overcome  by  osteotomy. 

Treatment  of  other  forms.  In  the  acute  tuberculous  form  early  incision 
and  drainage  are  more  frequently  required  and  the  greatest  care  should  be 
employed  to  prevent  general  infection.  In  the  fibroid  or  chronic  form  when 
abscesses  occur,  excision  is  more  frequently  necessary.  In  these  cases  also 
the  use  of  alteratives,  both  general  and  local,  will  be  found  of  signal  service. 


*  "  Ann.  of  Surg.,"  x.tv,  1S97,  p.  127. 


I'iG.  328. — Unilateral  Hip-joint  Disease  after  Excision. 


Fig.  329. — ^Severe  Form  of  Femoral  Hip  Disease  (Case  of  Dr.  W.  P.  Bolles). 


CHAPTER  V. 
NON-TUBERCULOUS  DISEASES  OF  THE  HIP. 

The  affections  of  the  hip  non-tuberculous  in  nature  include  about  25  per 
cent,  of  all  the  affections  of  the  hip;  by  far  the  larger  number  being  tuberculous. 

According  to  Konig,*  the  relative  frequency  and  the  degree  of  importance 
of  the  different  affections  of  the  hip-joint  causing  disability  are  as  follows: 

1.  Tuberculous  disease, 568 

2.  Acute  infectious  arthritis  after  typhoid  fever,  scarlatina,  etc., no 

Coxa  vara, S 

Tumors, 2 

3 .  Gonorrheal  arthritis, 30 

4.  Arthritis  deformans, 22 

5.  Contractions  and  ankylosis,  cause  unknown, 6 

6.  Pyemic    suppuration, 3 

7.  Injuries, 11 

Total, 7S7 

Traumatism. 

Injury  or  strain  of  the  hip  in  young  children  frequently  produces  a  condition 
closely  resembling  hip  disease  and  often  confounded  with  it.  The  characteristic 
symptoms  of  affections  of  traumatic  origin  in  the  hip  are  pain  and  discomfort 
consequent  upon  any  overexertion,  which  is  felt  particularly  at  night.  The 
pain  experienced  is  such  as  is  commonly  known  by  as  "growing  pains,"  and 
there  is  sometimes  limitation  of  motion  with  a  slight  limp.  The  injury  is  liable 
to  cause  a  congestion  in  the  region  of  the  head  of  the  femur  and  around  the 
cartilage,  and  this  congestion,  in  connection  with  the  resulting  lessening  of  the 
local  resistance,  may  be  a  cause  of  subsequent  tuberculous  affection  of  the  joint. 
If  the  injury  be  very  severe,  the  joint  may  become  enlarged  and  sensitive  upon 
motion  or  pressure,  and  may  be  followed  by  a  synovitis. 

The  treatment  for  traumatic  affections  of  the  hip  consists  in  extension 


■  "Die  Specielle  Tuberculose  der  Knochen  und  Gelenke,"  "  Das  Hoftgelenk,"  Berlin,  1902,  vol.  ii,  p.  3. 

375 


376  ORTHOPEDIC  SURGERY. 

in  bed,  with  counter-irritation,  which  should  be  continued  for  several  weeks, 
and  until  all  the  symptoms  have  entirely  disappeared. 

Synovitis  of  the  Hip-joint. 

The  hip  is  subject  to  the  different  forms  of  synovitis  described  elsewhere — 
acute  serous,  chronic  serous,  and  chronic  joint  hydrops. 

The  causes  of  acute  synovitis  of  the  hip  are  many  and  varied.  It  may 
result  from  traumatism,  exposure  to  cold  or  dampness,  or  it  may  result  from 
over-exertion.  It  may  occur  as  a  part  of  a  general  inflammatory  condition, 
as  acute  articular  rheumatism,  syphilis,  or  gout,  and  very  frequently  it  occurs 
as  a  sequel  to  infectious  diseases,  such  as  a  pyemic  process  in  pneumonia, 
scarlatina,  typhoid  fever,  pyemia,  septicemia,  diphtheria,  erysipelas,  dysentery, 
puerperal  fever,  smallpox,  measles,  typhus,  and  varicella. 

In  many  of  the  infections  the  particular  germ  of  the  disease  has  been  formed 
in  the  synovial  fluid,  but  in  some  the  ordinary  germs  of  suppuration  have  been 
found  without  any  specific  organism,  and  in  some  the  fluid  evacuated  has  been 
found  infectious,  as  in  gonorrhea,  from  pure  cultures,  without  the  presence 
of  the  specific  germs  of  suppuration. 

In  the  majority  of  instances  the  hip  is  less  frequently  affected  than  the 
other  large  joints.  This  is  well  shown  in  a  series  of  cases  collected  by  Lovett* 
from  various  sources  and  shown  in  the  following  table: 

The  knee  was  affected 357  times 

The  ankle  was  afiected 284  times 

The  wrist  was  affected 249  times 

The  shoulder  was  affected 229  times 

The  elbow  was  affected 148  times 

The  hip  was  affected 103  times 

The  fingers  were  affected 81  times 

The  feet  were  affected 45  times 

The  hands  were  affected 44  times 

The  toes  were  affected 29  times 

The  spine  was  affected 16  times 

Miscellaneous  joints 8  times 

1593  times 

•  The  same  is  also  shown  in  the  series  of  375  cases  of  gonorrheal  infection 
collected  by  Frazier,  in  which  the  hip  was  affected  18  times  and  the  knee  136 
times. 


♦  "Diseases  of  the  Hip-Joint,"  iSgi. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  ■  377 

Symptoms. — The  chief  symptoms  are  weakness,  stiffness,  and  severe 
pain  on  motion.  On  account  of  the  deep  location  of  the  joint,  swelling  is  difi&cult 
of  detection  during  the  early  stage,  but  later  the  surrounding  structures  become 
baggy  and  edematous.  The  general  condition  is  at  first  not  influenced  by 
the  joint  infection,  but  subsequently  upon  the  formation  and  rupture  of  pus 
into  the  surrounding  structures  the  constitutional  symptoms  are  marked  and 
alarming.  When  the  joint  infection  occurs  as  a  complication  in  the  course 
of  a  disease,  the  symptoms  are  pyemic  in  character. 

Treatment. — The  treatment  of  simple  acute  synovitis  consists  of  bed 
extension  and  counter-irritation, — a  fly-blister  applied  back  of  the  trochanter 
wUl  be  found  useful  in  the  milder  forms,  and  ichthyol  ointment,  50  per  cent., 
combined  with  lanolin  and  petrolatum  to  which  has  been  added  a  few  drops 
of  oU  of  citronella,  will  be  found  a  useful  application.  If  the  symptoms  do 
not  quickly  subside,  the  joint  should  be  aspirated  behind  the  trochanter.  If 
the  fluid  obtained  be  purulent,  a  free  incision  of  the  joint  should  at  once  be 
made.  This  can  best  be  accomplished  by  an  incision  posterior  to  the 
trochanter,  or,  if  fluctuation  be  detected  in  front  in  the  adductor  region,  the 
anterior  incision  described  under  excision  of  the  hip  may  be  used,  or  through 
a  skin  incision  in  the  adductor  region,  the  muscles  may  be  separated  and  the 
joint  be  readily  incised. 

Ankylosis  is  liable  to  follow  this  condition,  and  should  be  overcome  by 
forcible  correction  in  mild  cases,  but  in  severe  cases  osteotomy  may  be  necessary. 

Deformity  is  sometimes  very  great  from  the  abduction  and  flexion  of  the 
femur,  the  limb  being  fixed  at  a  right  angle  to  the  body  and  carried  far  out 
to  one  side. 

Chronic  Serosynovitis  of  the  Hip. 

The  acute  condition  may  become  chronic  or  it  may  be  primarily  chronic 
from  other  causes  than  tuberculosis  and  arthritis  deformans,  or  it  may  through- 
out its  course  consist  in  an  inflammation  without  excessive  secretion  of 
the  synovial  fluid, — a  dry  synovitis,  or  the  so-called  arthrite  plastique  ankylosante. 
The  main  causes  of  chronic  synovitis  have  already  been  described  under  the 
acute  condition.  The  chronic  condition  produced  by  exposure,  insufficient 
food,  and  unhygienic  surroundings  is  sometimes  described  as  arthritis  pauperum. 

Treatment. — The  treatment  consists  in  the  administration  of  tonics, 
anti-rheumatic  remedies,  together  with  improved  diet,  and  counter-irritation 
by  the  use  of  compound  iodin  ointment  or  the  actual  cautery. 


378  ■  ORTHOPEDIC  SURGERY. 

Acute  Arthritis  of  the  Hip-joint. 

This  affection  is  one  which  is  found  in  young  children,  chiefly  in  the  early 
weeks  of  life,  and  is  of  a  suppurative  character,  originating,  as  a  rule,  in  the 
epiphysis  and  from  thence  infecting  the  joint.  It  is  generally  pyemic  in  character, 
but  may  be  due  to  traumatism,  to  infection  of  syphilitic  or  suppurative  character, 
particularly  suppuration  of  the  umbilicus,  or  it  may  sometimes  occur  as  a  sequel 
of  diseases  common  to  childhood,  such  as  chicken-pox,  measles,  scarlatina, 
or  as  a  result  of  typhoid  fever,  or  it  may  be  due  to  pertussis.  The  origin  is  obscure 
and  difficult  to  determine.  The  infecting  germ  is  usually  the  staphylococcus 
aureus  or  albus,  or  the  streptococcus. 

The  disease  is  characterized  by  a  sudden  onset,  and  there  is  usually  a 
considerable  elevation  of  temperature,  the  child  being  greatly  prostrated.  There 
is  swelling  in  the  hip,  with  sensitiveness  upon  motion  or  palpation.  Suppuration 
is  an  early  and  persistent  feature  of  the  affection,  and  the  usual  course  is  the 
destruction  of  the  epiphysis,  with  a  consequent  loosening  of  the  joint,  giving 
the  appearance  in  cases  which  have  recovered  of  an  apparent  congenital  disloca- 
tion. On  account  of  the  septic  nature  of  the  disease  it  is  sometimes  difficult 
to  differentiate  it  from  tuberculosis,  and  in  less  severe  cases  this  may  only  be 
done  by  making  a  bacteriologic  examination  of  fluid  aspirated  from  the  joint. 

Treatment. — The  treatment  should  consist  first  in  an  effort  to  check  and 
overcome  the  septic  process  of  destruction,  and  to  this  end  early  and  efficient 
drainage  should  be  carried  out,  making  a  free  incision;  where  it  is  possible, 
the  line  used  for  resection  of  the  joint  should  be  followed,  and  the  joint  entered 
back  of  the  femur.  The  drainage  should  be  so  thorough  that  no  drainage-tubes 
need  be  used.  The  presence  of  fluctuation  and  cellulitis  is  the  indication  for 
the  free  incision  and  drainage,  and  cannot  be  undertaken  at  too  early  a  period. 
After  the  drainage  is  established  the  area  should  be  left  open,  with  only  the 
application  of  some  simple  antiseptic  poultice  or  dressing,  as  it  is  well  under- 
stood that  children  in  the  early  months  of  life  stand  corrosive  dressings  very 
well.  If  the  child  be  very  feeble,  the  incision  may  be  quickly  made  without 
anesthesia,  and  subsequently  the  carious  bone  may  be  removed ;  but  if  the  child 
be  strong,  the  diseased  bone  may  be  removed  at  once  under  an  anesthetic. 
The  joint  should  be  given  as  much  rest  as  possible,  and  because  of  the  intense 
sensitiveness  which  characterizes  the  affection,  the  diseased  joint  should  be 
fixed  by  mechanical  means  in  order  to  relieve  this  condition.  The  hip  is  usually 
flexed  in  acute  arthritis  and  should  be  fixed  in  this  position,  as  any  attempt 
at  correction  would  cause  unnecessary  suffering  to  the  patient.     For  purposes 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  379 

of  fixation  either  an  anterior  pasteboard  splint  or  a  plaster-of-Paris  spica  bandage 
may  be  used.  Ankylosis  is  liable  to  follow,  and  in  view  of  this  fact  the  joint 
should  be,  if  at  all  possible  in  the  earlier  stages  of  the  affection,  fixed  in  as  favor- 
able a  position  as  possible,  but  if  ankylosis  in  a  faulty  position  should  occur, 
the  after-treatment  may  be  the  same  as  in  hip  disease. 

The  prognosis  is  generally  favorable,  especially  in  cases  where  the  affection 
is  in  one  joint  only  and  the  shaft  of  the  bone  is  not  diseased,  and  where  a 
thorough  early  evacuation  of  the  pus  has  been  accomplished;  but  death  may 
occur  from  the  suppurative  infection.  In  twelve  cases  reported  by  Townsend* 
there  were  three  deaths.  Recovery  is  apt  to  be  attended  with  a  certain  degree 
of  deformity,  and  because  of  this,  the  joint  should  be  carefully  supported  for 
some  time  after  the  disease  has  run  its  course,  to  avoid  the  danger  of  upv/ard 
displacement.  The  most  characteristic  deformity  resulting  from  the  destruction 
of  the  epiphysis  is  an  upward  and  backward  displacement,  closely  resembling 
that  of  congenital  dislocation,  and  this  may  be  corrected,  under  anesthesia, 
in  much  the  same  manner  as  that  of  Lorenz  for  the  reposition  of  congenital 
luxation  of  the  hip. 

A  full  bibliography  upon  this  subject,  together  with  a  tabulation  of  reported 
cases,  may  be  found  in  the  article  by  Townsend  mentioned  above. 

Arthritis  Deformans  of  the  Hip-joint. 

The  general  subject  of  rheumatic  arthritis  will  be  described  in  the  special 
chapter  devoted  to  this  subject.  Since  the  disease  is  frequently  confined  to 
the  hip-joint,  this  phase  of  the  subject  may  be  described  here. 

When  the  hip-joint  is  the  seat  of  the  affection,  it  is  known  as  malum  cox(e 
senilis.  S3Tionyms:  malum  senile,  morbus  coxce  senilis,  senile  coxitis.  The 
origin  of  this  disease  has  been  variously  ascribed:  to  the  synovial  membrane 
by  Brodie,  Adams,  Volkmann,  and  qthers;  to  the  cartilage  by  Cornil  and  Ran- 
vier,  Orth,  Howard  Marsh,  Billroth,  and  Garrod;  and  to  the  bone  by  Bar- 
well  and  others.  It  is  also  called  rheumatic  or  rheum.atoid  arthritis,  rheu- 
matic gout,  osteoarthritis,  nodular  rheumatism,  rheumatisme  noueux,  etc.  The 
pathologic  differences  are  so  insignificant  that  it  is  more  practical  to  con- 
sider them  under  one  disease. 

Injury,  age,  and  strain  of  the  part  are  important  local  factors  in  causing 
this  affection,  and  it  is  likely  to  follow  fractures  of  the  hip-joint  in  the  aged. 

*  "American  Journal  of  Medical  Science,"  January,  1S90. 


3S0  ORTHOPEDIC  SURGERY. 

The  chief  characteristics  are  disintegration  and  erosion  of  the  articular 
cartilages  and  a  tendency  to  increased  bony  formation  about  the  head  of  the 
femur.  There  has  been  much  discussion  as  to  whether  the  changes  are  in- 
flammatory or  not.  Senator  expresses  the  modem  conclusion  as  follows:  "The 
changes  in  the  joints  are  partly  inflammatory,  partly  degenerative."  In  the 
early  stage  the  synovial  fluid  is  increased,  and  later  it  is  decreased.  Changes 
in  the  cartilages  are  noted  in  the  earlier  period  of  the  disease,  the  ceUs  multiply 
and  there  is  fibrillary  degeneration  of  the  hyaline  substance  which  renders 
the  cartilage  more  friable  than  normal.  It  has  a  yellowish  appearance  and 
the  articular  surfaces  become  thinned  in  the  center  and  hypertrophied  around 
the  periphery.  MicroscopicaUy  it  appears  velvety,  and  pieces  may  be  split 
off.  ■  Marginal  ecchondroses  appear  which  may  become  so  large  as  to  perforate 
the  s)aiovial  membrane,  and  become  pedunculated  or  even  detached.  Ossi- 
fication of  these  ecchondroses  begins  in  the  layers  nearest  the  bone. 

The  early  symptoms  are  neuralgic  pains  in  the  limb,  "sciatic  rheumatism," 
stiffness  and  sensitiveness  to  pressure.  The  movements  of  the  joints  are  re- 
stricted, and  there  may  be  a  creaking  of  the  joints.  In  the  advanced  stages 
there  is  marked  thickening  around  the  trochanter,  the  limb  is  shortened  and 
distorted,  and  is  held  in  a  position  of  flexion  and  adduction,  and  atrophy  is 
marked. 

Treatment. — When  limited  to  a  single  joint,  the  advance  of  the  disease 
may  be  arrested  by  improving  the  general  health  of  the  patient,  and  the  ad- 
ministration of  stimulants,  together  with  the  use  of  massage  and  passive  motion. 
Traction  with  recumbency  should  be  employed  for  the  reduction  of  the  de- 
formity, and  later  a  fixation  hip  apparatus  or  support  may  be  applied  with 
positive  advantage.  Resection  of  the  upper  portion  of  the  femur  may  be  re- 
quired in  very  severe  cases,  and  successful  operations  of  this  character  are  referred 
to  under  the  general  subject.  In  the  majority  of  instances  where  treatment  by 
neither  operative  nor  mechanical  means  is  feasible  a  strong  spica  bandage, 
with  the  occasional  use  of  the  cautery,  vnll  afford  the  patient  considerable  relief. 

Irritation  due  to  arthritis  deformans  is  treated  largely  by  the  same  meas- 
ures as  joint  irritation  from  other  causes — the  administration  of  tonics,  salicylate 
of  soda  and  alkaline  diuretics,  Vichy  water,  and  the  local  use  of  massage,  elec- 
tricity, with  rest  and  protection  to  the  joint.  A  visit  to  one  of  the  foreign  spas 
or  health  resorts  will  frequently  be  found  beneficial. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  381 

Syphilis  of  the  Hip-joint. 

The  local  manifestation  of  lues  in  the  hip-joint  is  characterized  by  a  chronic 
synovitis  with  gummatous  formations  scattered  through  the  synovial  mem- 
brane, the  bones,  and  the  surrounding  structures.  Necrosis,  disintegration,  and 
pus  formation  occur,  together  with  a  hypertrophic  periosteitis,  or  perichondritis, 
especially  of  the  epiphysis  of  the  head  of  the  femur. 

It  is  most  common  in  early  life  as  an  inherited  lesion,  during  the  first 
year  of  life,  and  later  from  the  fourth  to  the  twentieth  year. 

As  an  acquired  affection  it  is  first  apparent  in  the  synovial  membrane; 
gummatous  formations  are  developed,  especially  beneath  the  periosteum, 
and  with  a  tendency  to  cicatrization,  resulting  in  false  ankylosis. 

Symptoms. — The  symptoms  resemble  somewhat  those  of  tuberculous 
osteitis.  The  joint  outline  is  distinctly  enlarged  and  indurated,  the  capsule  is 
thickened,  but  the  fusion  is  so  slight  that  it  cannot  be  detected  upon  palpation. 
Motion  is  limited,  but  there  is  an  absence  of  the  reflex  muscular  spasm  which 
is  present  in  tuberculous  joint  disease,  or,  if  present,  it  is  not  so  marked,  and 
the  atrophy  which  occurs  is  slight.  Pain  is  moderate  upon  motion  and  may 
be  elicited  by  firm  local  pressure.     Night-cries  are  absent. 

Treatment. — The  treatment  should  consist  in  the  administration  of 
large  doses  of  potassium  iodid,  or  Donovan's  solution  administered  in  medium- 
sized  doses  will  be  found  of  advantage,  together  with  the  local  application 
of  mercurial  ointment.  The  general  condition  should  be  improved  in  every 
way,  and  some  preparation  of  iron  will  be  found  beneficial  as  a  tonic.  The 
joint  should  be  placed  at  rest  by  extension  or  the  use  of  a  hip  splint,  and 
subsequently  motion  should  be  restored  by  forcible  means. 

Neuropathic  Affections  of  the  Hip-joint. 

The  neuropathic  affections  of  the  joints  described  by  Charcot  as  being 
the  result  of  any  lesion  of  the  anterior  cornua  of  the  cord  are  frequently  observed 
in  the  hip-joint.  In  169  cases  analyzed  by  Weizsacher  the  knee  was  affected 
78  times,  the  hip  31  times,  and  the  shoulder  21  times,  etc.  The  pathologic 
condition  in  the  hip  resembles  the  lesion  in  arthritis  deformans.  There  is 
marked  effusion  with  thickening  of  the  S3Tiovial  membrane,  there  is  exostosis 
of  bone,  and  the  trochanter  is  found  on  a  higher  plane  than  normal. 

Treatment. — The  treatment  should  be  directed  to  the  condition  which 
is  the  cause  of  the  arthropathy.  In  many  instances  little  can  be  accomplished 
by  medical  treatment.     If  there  is  a  history  of  syphilis,  large  doses  of  potassium 


382  ORTHOPEDIC  SURGERY. 

iodid,  with  or  without  mercury,  should  be  administered.  If  the  joint  be  greatly 
distended  by  fluid,  aspiration  will  be  indicated.  Traction  hip  splints  are  of 
some  value  in  alla}ang  the  pain,  but  are  not  always  available  because  of  the 
toxic  condition.  Incision  of  the  joint  has  been  performed,  but  is  not  to  be 
recommended  on  account  of  the  disturbed  trophic  condition  of  the  parts. 

Malignant  Disease  of  the  Hip. 

The  occurrence  of  malignant  disease  of  the  hip  is  extremely  rare:  in  70 
cases  of  sarcoma  of  the  femur  analyzed  by  Gross  there  were  only  two  affecting 
the  upper  epiphysis;  but  the  affection  is  of  sufficient  frequency  to  demand 
consideration  here. 

The  mahgnant  growth  is  usually  a  sarcoma,  carcinoma  of  the  bone  being 
seldom  met  with.  The  round-cell  sarcoma  of  the  periosteum  is  the  variety 
usually  aft'ecting  the  hip,  being  the  most  rapidly  growing  of  malignant  tumors 
found  in  this  locality.  There  is  little  or  no  bone  formation  and  considerable 
bone  destruction.  These  tumors  are  excessively  vascular,  and  are  alveolar 
in  character,  resembling  somewhat  the  structure  of  carcinomas,  ha^^ng  the 
appearance  of  aneurysm,  with  a  slight  degree  of  pulsation.  The  fact  that 
suppuration  is  ver}-  sUght  renders  a  differential  diagnosis  from  tuberculous 
affections  of  the  bone  comparatively  easy.  There  is  infiltration  of  the  soft 
parts,  with  an  occasional  spontaneous  fracture,  but  this  latter  condition  is 
found  less  frequently  in  the  hip  than  in  other  malignant  tumors  of  the  bones. 

The  symptoms  of  malignant  disease  of  the  hip  are  the  early  and  rapid 
swelling  of  the  part,  some  limitation  of  motion,  with  a  sHght  limp.  Tlie  swelling 
increases^ as  the  disease  advances,  aad  in  time  the  entire  limb  becomes 
distressingly  large.  Intense  pain  sometimes  characterizes  the  affection,  while 
in  other  cases  it  is  so  slight  as  to  cause  little  discomfort.  There  is  no  fluctuation 
present. 

The  treatment  of  this  aft'ection  is  not  satisfactory,  the  only  methods  which 
give  any  hope  of  cure  being  amputation  at  the  hip  or  exarticulation  of  the  hip- 
joint,  and  this  operation  should  be  performed  as  early  as  possible  after  the 
diagnosis  of  malignant  disease  has  been  established,  in  order  to  insure  any 
chance  of  recovery.  It  is,  however,  rarely  successful  as  a  curative  means. 
Exarticulation  of  the  hip  at  the  highest  point  has  been  attempted  with  but 
small  success.     There  have  been  reported  (AVyeth*  and  Jenckelf)   22  cases 

*  "Ann.  of  Surg.,"  igoi,  vol.  x.^v,  p.  375.  f  "Deutsch.  Zeit.  f.  Chir.,"  1902,  Bd.  Ixiv,  p.  66. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  383 

of  malignant  growths  in  the  hip  which  have  been  cured  by  exarticulation  or 
amputation,  the  patients  Hving  from  three  to  sixteen  years  after  the  operation; 
but  in  the  majority  of  these  cases  the  growth  was  below  the  epiphysis,  and  only 
a  very  small  percentage  of  cured  cases  of  sarcoma  of  the  upper  end  of  the  femur 
have  been  reported. 

Kramer  *  has  studied  extensively  the  results  of  various  operations  for 
sarcomas  of  the  bones,  and  because  of  his  exhaustive  consideration  of  the  sub- 
ject his  conclusions  should  take  precedence  over  those  of  other  writers.  He, 
with  other  authorities,  is  agreed  that  only  in  cases  of  malignant  disease  of  the 
upper  femoral  shaft,  or  where  infiltration  of  muscle  is  excessive,  is  there  neces- 
sity for  exarticulation.  Borckf  in  87  cases  of  exarticulation  for  sarcoma  of 
the  hip  was  unable  to  find  a  case  positively  cured. 

Bloodgood  suggests  that  the  literature  upon  the  subject  of  sarcomas  of 
the  bone  demonstrates  that  the  nature  of  the  tumor  should  indicate  the  form 
of  operation  required.  There  are  the  two  varieties  of  sarcoma,  and  only 
in  the  most  malignant  t)qDe  would  exarticulation  be  demanded,  or  perhaps  in 
cases  not  so  malignant  in  character  where  the  location  of  the  tumor  or  the  pres- 
ence of  infiltration  of  the  soft  tissues  warrants  this  mode  of  procedure.  This 
theory  has  been  corroborated  by  a  careful  study  of  results  obtained  in  operative 
treatment  for  malignant  growths  in  the  bones,  for  thirteen  consecutive  years 
in  the  Johns  Hopkins  Hospital,  collected  by  Kramer  and  Jenckel. 

When  exarticulation  has  been  performed  for  malignant  tumors  of  the 
hip,  the  wound  may  be  inoculated  after  the  operation  either  with  the  strepto- 
coccus of  erysipelas,  or  if  not  with  this,  perhaps  with  the  toxins  of  streptococcus 
and  the  Bacillus  prodigiosus,  which  has  been  recommended  by  Coley  in  the 
treatment  of  malignant  tumors  in  any  locality.  The  object  of  inoculating 
the  wound  is  to  avoid  the  possible  danger  of  recurrence.  There  is  always  the 
danger  of  internal  metastasis. 

The  final  result  of  operation  in  malignant  disease  of  the  bone,  even  in 
the  most  hopeful  cases,  is  uncertain.  According  to  Kxamer,  the  results  after 
resection  and  after  amputation  are  equally  satisfactory,  provided  the  tumor 
has  affected  only  the  bone  and  there  is  no  infiltration  of  the  soft  parts.  If 
this  latter  condition  exists,  exarticulation,  with  the  removal  of  the  area  of  infil- 
tration, would  probably  be  more  successful,  except  that  death  is  apt  to  result 
from  internal  metastasis.     Resection  is  seldom  employed  in  sarcoma  of  the 

*  "  Archiv  f.  klin.  Chir.,"  1902,  Bd.  Ixvi,  p.  792.  f  "Archiv  f.  klin.  Chir.,"  1890,  Bd.  xl,  p.  941. 


384  ORTHOPEDIC  SURGERY. 

hip,  as  the  area  of  infection  is  extensive,  infiltration  of  the  soft  tissues  is  present, 
and  the  occurrence  of  metastasis  is  probable.  Resection  has  been  advocated 
by  Mikulicz  and  Weistnger. 

The  ultimate  conclusion  based  upon  a  careful  consideration  of  all  of  the 
literature  upon  malignant  growths  in  the  bones  is  that  under  certain  selected 
conditions  resection  may  safely  be  undertaken;  that  in  the  most  malignant 
tumors,  accompanied  by  muscle  infiltration,  exarticulation  is  required;  and 
that  in  the  greater  number  of  cases  amputation  gives  the  best  results  and  the 
most  hope  of  recovery.  A  most  notable  case  of  a  cure  of  metastatic  carcinoma 
at  the  upper  end  of  the  femur,  by  exarticulation,  is  reported  by  Rose.*  In 
this  instance  the  carcinoma  of  the  hip  was  secondary  to  an  excision  for  car- 
cinoma of  the  breast. 

Coxa  Vara. 

Definition. — Coxa  vara  is  the  term  applied  to  that  deformity  in  the  upper 
end  of  the  femur  in  which  the  normal  angle  formed  by  the  neck  and  the  shaft 
of  the  bone  is  lessened. 

Synonyms. — English,  Bending  of  the  neck  of  the  femur;  Depression  or  in- 
curvation of  the  neck  of  the  femur.  French,  Deformations  du  col  du  femur. 
German,  Schenkelhals  Verbiegungen.  Italian,  Coxovaro,  Collum  femoris 
varum;   Coxa  adducta.     Spanish,  Coxovaro. 

History. — Coxa  vara  as  a  distinct  deformity  has  been  unrecognized  until 
very  recent  years.  While  there  have  been  cases  reported  by  Roser,  1843; 
Zeis,  1851;  Richardson,  1857;  Monks,  1886;  Keetly,  1888;  that  were 
undoubtedly  true  cases  of  coxa  vara,  our  attention  was  first  called  to  it  as  a 
deformity  distinct  from  hip  disease  by  Fiorani,  1881.  E.  MuUer,  1889,  re- 
ported four  cases  occurring  in  adolescence  in  which  he  described  the  condition 
present  as  a  distinct  affection  from  hip  disease,  and  to  him  is  given  the  credit 
for  the  first  detailed  description  of  the  disease.  To  Hofmeister  is  given  the 
credit  for  the  term  "coxa  vara." 

Etiology. — The  following  theories  have  been  advanced  from  time  to  time 
to  account  for  the  various  forms  of  coxa  vara. 

1.  Congenital:  That  cases  of  congenital  coxa  vara  are  due  to  malposition 
of  the  fetus  in  utero. 

2.  Pathologic:    Some  writers  consider  that  the  condition  is  caused  by  a 


*  "  Centralblatt  f.  Chir.,"  1902,  Bd.  xxix,  p.  17. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  385 

local  disease  in  the  neck  of  the  femur,  as  osteomalacia,  osteomyelitis,  rachitis, 
arthritis  deformans,  etc.,  and  that,  as  a  result  of  the  weakened  condi- 
tion present,  any  increase  in  weight  it  is  required  to  bear  results  in  a  diminu- 
tion of  the  normal  angle  of  the  femoral  neck. 

3.  Structural  Weakness;  Static  Theory:  In  certain  cases  there  is  probably  an 
inherited  delicacy  of  structure  of  the  support,  and  any  increase  in  the  burden, 
whether  for  a  shorter  or  longer  period,  is  liable  to  produce  the  deformity. 

4.  Inherent  Weakness:  Some  writers  consider  the  deformity  to  be  due  to 
overburdening,  and  classify  it  with  genu  valgum  infantum  and  adolescentium. 
Rachitis  in  the  infantile  form  or  late  rachitis  in  the  adolescent  may  be 
associated,  although  in  the  adult  form  the  signs  of  rachitis  are  often  absent. 

5.  Traumatism:  This  form  is  shown  in  those  cases  in  which  the  deformity 
is  caused  by  a  fracture  between  the  head  and  the  neck  of  the  femur  at  the 
epiphyseal  line,  or  occasionally  by  a  fracture,  complete  or  incomplete,  through 
the  neck  of  the  femur. 

6.  Anatomic:  (Sudeck's  Theory.)  In  a  study  of  the  system  of  the  bone 
lamellas  of  the  upper  end  of  the  femur,  two  systems  are  found  to  be  present: 
one  on  the  adduction  side,  which  sustains  the  weight  of  the  body,  and  one  on 
the  trochanteric  side,  which  sustains  the  tension,  known  respectively  as  the 
pressure  bow  and  the  tension  bow  systems.  Examination  of  the  neck  of  the 
normal  adult  femur  shows  a  ridge  extending  from  the  border  of  the  articulating 
cartilage  of  the  head  downward  and  outward  over  the  anterior  surface.  This 
ridge  represents  the  highest  and  strongest  part  of  the  tension  bow  and  pre- 
vents a  bending  down  and  back  of  the  neck.  Any  insufficiency  of  the  tension 
bow  which  allows  a  bending  of  the  neck  downward  and  backward  may  cause 
coxa  vara.  This  insufficiency  may  be  caused  by  a  softening  or  late  ossifica- 
tion of  this  system  of  lamellas,  or  by  an  overburdening  during  the  period  of 
growth  when  the  lamellas  have  not  acquired  their  normal  adult  firmness. 

Classification. — For  convenience  and  until  some  definite  cause  can  be 
ascribed  for  each  individual  case,  coxa  vara  may  be  broadly  divided  into: 

(A)  Coxa  Vara  Adolescentium. 

Having  a  cause  common  with  genu  valgum  and  varum. 

(B)  Other  forms  of  Coxa  Vara. 

1.  Congenital. 

2.  Associated  with  congenital  dislocation  of  the  hips. 

3.  Due  to  Osteomalacia. 

4.  Due  to  Acute  Osteomyelitis. 


3S6 


ORTHOPEDIC  SURGERY. 


5.  Due  to  Osteitis  Fibrosa. 

6.  Due  to  Tuberculosis. 

7.  Due  to  Senile  Atrophy. 

8.  Due  to  Arthritis  Deformans. 

9.  Due  to  Causes  Unknown. 
10.  Due  to  Traumatism. 

Coxa   Vara  Adolescentium. — Age:    In  a   series  of  eight3'-three   cases 
from  the  literature  of  coxa  vara  the  age  varies  as  follows:   six  congenital;  five 


Fig.  330. 
a,  Co.xa  vara;  b,  normal  femur;  c,  coxa  valga  (Wistar  Institute  of  Anatomy). 


between  two  and  five  years;  five  between  six  and  seven  years;  two  between 
seven  and  eight  years;  seven  between  nine  and  ten  3'ears;  one  between  ten 
and  eleven  years;  three  between  twelve  and  thirteen  years;  four  between 
thirteen  and  fourteen  years;  eleven  between  fourteen  and  fifteen  years;  nine- 
teen between  fifteen  and  sixteen  years;  eleven  between  sixteen  and  seventeen 
years;  three  between  seventeen  and  eighteen  years;  two  between  eighteen 
and  nineteen  years;  two  between  twenty  and  twenty-one  years:  and  one  at 
twentv-four  vears. 


.      NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  387 

Sex:  From  109  cases  selected  from  the  literature,  83  were  in  males  and 
26  in  females,  85  were  unilateral  and  24  bilateral. 

Deformity:  In  a  review  of  68  cases  of  non-traumatic  coxa  vara  it  was 
found  that  the  bending  of  the  neck  is  usually  downward  and  backward,  following 
the  line  of  the  least  resistance,  as  shown  by  Sudeck's  theory.  Occasionally 
only  downward,  and  rarely  downward  and  forward,  as  a  result  of  the  bending 
of  the  neck  downward  and  backward,  there  is  elevation  of  the  trochanter  and 


Fig.  331. 
a,  Co.xa  valga,  vertical  section;    b,   normal  femur,   vertical   section;    c,  co.xa  vara,  vertical  section  (Wistar 

Institute  of  .\natomy). 

outward  rotation  of  the  thigh,  the  former  accounting  for  the  shortening,  the 
latter  for  the  limitation  of  inward  rotation. 

Angle  of  Deformity:  In  examining  the  normal  femur  of  an  adult  the 
angle  formed  by  the  neck  and  shaft  is  about  125  degrees.  In  earlier  life  the 
angle  is  greater,  in  children  being  about  130  to  140  degrees,  and  as  one  advances 
in  adult  life  the  angle  gradually  lessens  to  perhaps  no  degrees.  Between 
no  and  140  degrees  may  be  considered  within  normal  limits.  In  coxa  vara 
the  angle  formed  by  the  neck  and  shaft  of  the  femur  may  vary  from  90  to  40 
degrees.     The  following  table  gives  the  position  of  the  lower  extremity  in  86  cases : 


388  ORTHOPEDIC  SURGERY. 

VARIATION  IN  POSITION  OF  LIMB.     (FRAZIER  AND  HOFMEISTER.) 


Position  of  Lists . 


Outward  rotation, 

Outward  rotation  and  adduction, . 
Outward  rotation  and  flexion, . . . . 

Inward  rotation 

Inward  rotation  and  adduction, . . 

Adduction, 

Adduction  and  flexion, 

Normal, 


HOFMEISTER.  FrAZIER.  ToTAL. 


27  16 

5 

5 


In  reference  to  the  deformity  cases  may  be  divided  into  the  three  following 
groups  (Hofmeister) : 

Group  I:  Elevation  of  the  trochanter  and  limited  abduction  are  the 
characteristic  features.  The  attitude  of  the  limb  is  usually  normal,  flexion 
and  rotation  being  either  normal  or  limited  to  a  slight  degree. 

Group  II:  Elevation  of  the  trochanter  and  outward  rotation.  In  addition 
to  the  limited  abduction  associated  with  cases  in  Group  I,  we  find  in  this  group 
that  inward  rotation  is  so  restricted  that  it  is  impossible  to  rotate  the  limb  further 
inward  than  to  a  position  in  which  the  foot  points  directly  forward.  Outward 
rotation  may  be  possible  only  to  a  normal  degree,  or  so  far  beyond  the  normal 
that  the  patella  and  foot  may  point  not  only  directly  outward  but  backward. 
Abduction  and  adduction  are  as  described  in  Group  I,  the  former  being  markedly 
restricted  or  altogether  abolished,  the  latter  entirely  free.  In  the  majority 
of  cases  flexion  is  unrestricted  except  when  attended  with  outward  rotation 
and  adduction  of  the  thigh, — that  is  to  say,  if  one  attempts  to  flex  the  limb 
he  must  at  the  same  time  adduct  it  and  rotate  it  outward,  or  he  will  soon  come 
to  a  point  where  further  flexion  is  restricted.  If  the  aft'ection  is  bilateral  it 
is  now  easily  seen  why,  when  both  thighs  are  flexed  simultaneously,  each 
leg  will  cross  over  its  fellow.  The  appearance  of  such  a  patient  is  also  quite 
characteristic,  and  it  is  commonly  spoken  of  as  the  "scissor-legged  deformity." 
The  gait  is  not  unlike  that  seen  in  cases  of  bilateral  congenital  luxation  of  the 
hip.  Through  the  co-operative  effect  of  outward  rotation  and  limited  abduction 
in  bilateral  cases  there  exist  certain  characteristic  restrictions  in  the  movements 
of  the  legs.  For  example,  such  a  patient  can  kneel  only  with  the  legs  crossed. 
The  explanation  of  this  is  apparent :  flexion  is  possible  only  when  the  limb  is 
rotated  outward,  and  spreading  of  the  thighs  (which  would  obviate  the  necessity 
of  crossing  the  legs)  is  quite  impossible,  since  abduction  is  restricted.  For  the 
same  reason  sitting  on  a  stool  with  the  legs  close  together  is  impossible,  and  stoop- 
ing over  to  pick  up  an  object  from  the  ground  is  difficult.     The  rationale  of 


N  ON -TUBERCULOUS  DISEASES  OF    THE  HIP.  389 

this  is  appreciated  when,  voluntarily  limiting  abduction  and  rotating  the  limb 
outward,  we  try  in  our  own  persons  to  touch  the  floor  with  our  hands.  Such 
an  act  is  only  made  possible  by  the  preternatural  mobility  of  the  vertebral  column. 

Group  III:  Elevation  of  the  trochanter  and  inward  rotation.  The 
functional  disturbances  of  this  group  correspond  with  those  of  Group  II,  with 
this  exception, — namely,  in  one  we  find  inward  and  in  the  other  outward  rota- 
tion. 

Most  cases  belong  to  Group  II. 

Symptoms :  The  adolescent  form  of  coxa  vara  usually  begins  in  childhood, 
but  more  commonly  at  the  beginning  of  puberty  without  apparent  cause.  In 
a  number  of  cases  there  is  the  previous  history  of  rachitis.  Other  cases  develop 
without  any  apparent  cause.  At  times  there  is  the  previous  history  of  over- 
exertion or  exposure. 

The  subjective  symptoms  come  on  insidiously,  the  patient  complains 
of  a  slight  limp  on  the  affected  side,  usually  preceded  by  an  indefinite  pain 
about  the  hip,  at  times  referred  to  the  knee.  Accompanying  these  symptoms 
are  awkwardness  of  gait,  stiffness,  and  a  feeling  of  weakness  about  the 
hip.  At  times  there  may  be  severe  pain  and  muscular  spasm  about  the 
hip,  usually  marked  after  exertion.  As  the  limp  becomes  more  noticeable 
there  begins  atrophy  of  the  thigh  muscles.  Concomitant  with  these  symptoms 
deformity  begins.  This  usually  consists,  as  above  described  (see  classifica- 
tion, Hofmeister's),  in  prominence  and  elevation  of  the  trochanter,  outward 
rotation  of  the  thigh,  upward  tilting  of  the  pelvis  on  the  affected  side,  limita- 
tion of  abduction,  inward  rotation  and  flexion  of  the  thigh,  elevation  of  the 
trochanter  above  Nelaton's  line,  actual  shortening  as  measured  from  the  an- 
terior superior  spine  of  the  ilium  to  the  internal  malleolus,  and  marked  apparent 
shortening. 

The  objective  symptoms  may  be  explained  by  the  condition  present  in 
the  neck  of  the  femur  and  the  altered  relations  of  the  trochanter  with  the  ace- 
tabulum. As  the  neck  of  the  femur  bends  usually  in  the  line  of  least  resistance 
(see  above,  Sudeck's  theory),  which  is  downward  and  backward,  the  trochanter 
is  elevated  above  Nelaton's  line  and  becomes  more  prominent,  from  its  altered 
position  at  the  atrophy  of  the  thigh  muscles;  at  the  same  time  the  shaft  of  the 
femur  is  rotated  outward.  This  elevation  of  the  trochanter  and  outward 
rotation  of  the  thigh  are  compensated  by  upward  tilting  of  the  pelvis  on  the 
affected  side  and  slight  flexion  of  the  thigh.  The  tilting  of  the  pelvis  accounts 
for  the  marked  apparent  shortening.     On  account  of  the  changed  position 


390 


ORTHOPEDIC  SURGERY. 


of  the  trochanter,  and  as  the  head  of  the  femur  is  not  displaced,  abduction 
is  necessarily  limited. 

In  bilateral  coxa  vara  the  patient  is  obliged,  on  account  of  the  limited 
amount  of  abduction  on  both  sides,  to  assume  a  very  awkward  gait,  commonly 
known  as  the  "scissors  gait."  Walking  at  times  is  extremely  difficult.  In 
some  cases,  instead  of  the  neck  being  bent  backward  and  downward,  there 
occurs    a    bendins:    forward    and    downward.       In    this    condition    there    is 


Fig.  332. — Coxa  Vaka,   Front 
View  (Robert  Jones). 


Fig.    32^. — S.-vME,    L.\terai, 
View. 


Fig.    334. — S.\ME,    Posterior 
View. 


inward   rotation  of  the  thigh,   limitation   of    abduction,    however,   remaining 
the  same. 

Duration  of  the  Acute  S}aTiptoms:  In  most  untreated  cases  of  coxa  vara 
the  duration  of  the  acute  symptoms  is  usually  from  one  to  four  years.  This 
is  especially  true  of  cases  occurring  during  adolescence,  while  in  those  occurring 
at  an  earlier  period  the  symptoms  cover  an  indefinite  length  of  time,  and  there 
are,    at    times,    exacerbations    of    s3-mptoms.     Under    appropriate    treatment, 


Fig.  335- — X-Ray  of  Same,  Left  Side. 


Fig.  336. — X-R.AY  of  S.\ue,  Right  Side. 


Fig.  337. — Coxa  Vara,  showing   "  Scissor-leg  "   De- 
formity (Morton). 


Fig.   5;S. — Same,  Posterioe  \"ie\v. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  395 

local  and  general,  the  subjective  symptoms  gradually  subside,  and  the  local 
condition  in  most  cases  becomes  sufificient  to  insure  sufficient  stability. 

Diagnosis :  This  is  in  most  cases  made  with  very  little  difficulty.  A  good 
history,  a  careful  examination,  keeping  in  mind  the  above  symptoms,  will 
generally  lead  to  the  diagnosis. 

Differential  Diagnosis:  Cases  simulating  adolescent  coxa  vara  are: 

1.  Congenital  dislocation  of  the  hip. 

2.  Hip  disease. 

3.  Local  diseases,   as  osteomyelitis,   osteomalacia,  arthritis  deformans. 

4.  Traumatic  coxa  vara. 

1.  Coxa  vara  may  be  distinguished  from  congenital  dislocation  of  the 
hip  on  the  following  grounds:  Coxa  vara  is  usuahy  an  acquired  condition. 
In  congenital  dislocation  there  is  the  history  of  abnormal  mobility  of  the  joint 
from  birth,  the  free  mobility  of  the  trochanter  being  present  upon  palpation 
of  the  head  and  neck  of  the  femur  beneath  the  tense  tissues  of  the  gluteal 
region  on  forced  flexion  and  adduction  of  the  thigh. 

2.  In  hip  disease  there  occurs  reflex  muscular  spasm,  marked  limitation 
of  motion,  absence  of  shortening  except  in  the  advanced  state,  usually  local 
evidences  of  inflammation  and  suppuration;  whereas  in  coxa  vara  the  muscu- 
lar spasm  occurs  but  rarely  and  then  only  after  prolonged  effort,  motion  is 
limited  only  in  abduction,  inward  rotation,  and  flexion  in  most  cases,  and  there 
is  early  appearance  of  shortening  and  absence  of  local  signs  of  inflammation 
or  suppuration. 

3.  From  local  disease,  as  osteomyehtis,  arthritis  deformans,  or  osteomalacia, 
etc.,  a  dift'erential  diagnosis  is  difficult,  and  is  possible  only  by  an  examination 
of  the  bone  at  the  seat  of  the  disease. 

4.  In  traumatic  coxa  vara  there  can  usually  be  obtained  some  history 
of  injury.  Examination  with  the  .v-ray  will  usually  show  in  the  traumatic 
form  an  epiphyseal  separation  of  the  head,  while  in  the  non-traumatic  variety 
the  deformity  will  be  found  in  the  neck. 

Pathology:  An  examination  of  19  specimens  obtained  by  operation  or 
autopsy  showed  that  the  curvature  of  the  neck  was  associated  with  supposed 
rachitis  in  3  cases,  with  juvenile  osteomalacia  in  2  cases,  with  arthritis  deformans 
in  2  cases,  fracture  of  the  neck  of  the  femur  in  2  cases,  congenital  in  3  cases, 
and  in  7  cases  microscopic  examination  showed  no  change  which  could  be 
attributed  to  any  known  disease. 

Granting   the   possibility   of   late   localized   rachitis,    cases   of   coxa    vara 


396 


ORTHOPEDIC  SURGERY. 


occurring  in  adolescence  should  be  ascribed  to  this  condition.  There  have, 
however,  been  no  cases  so  far  to  show  conclusively  this  condition.  The 
relationship  of  coxa  vara  adolescentium  and  in- 
fantile coxa  vara  has  been  established  by  observa- 
tions of  Fiorani,  Lesser,  Ogston,  Zender,  and  others. 
Kocher  was  inclined  to  consider  the  histologic 
changes  in  his  two  specimens  to  be  localized  osteo- 
malacia. 

Burns  and  Hansell  in  a  report  of  io6  cases  of 
acute  osteomyelitis  of  the  upper  end  of  the  femur 
have  observed  various  curvatures  and  deformities 
of  the  neck  of  the  femur. 

No  specimens  have  yet  been  presented  that 
show  conclusively  the  association  between  coxa  vara 
and  tuberculosis. 

Maydl  has  shown  clinically  that  arthritis  defor- 
mans juvenalis  and  coxa  vara  adolescentium  cannot 
be  differentiated.  He  was  able  to  make  the  diag- 
nosis only  at  operation.  The  most  recent  work  to 
attempt  to  explain  the  cause  of  this  condition  on 
an  anatomic  basis  is  that  given  above.  (Sudeck's 
theory.) 

Other  Forms  of  Coxa  Vara. — Congenital 
Coxa  \'ara:  Six  cases  have  been  reported.  This 
variety  is  no  doubt  caused  by  intrauterine  pressure 
on  account  of  bad  position  of  jcetus  in  utero. 

Coxa  Vara  Due  to  Osteomalacia:  Three  cases 
are  reported  in  which  the  bending  of  the  neck  of 
the  femur  was  undoubtedly  due  to  localized  or 
general  osteomalacia.  One  case  occurred  in  a 
puerperal  woman. 

Coxa  Vara  Due  to  Acute  Osteomyelitis:  In  a 
series  of  io6  cases  of  acute  osteomyelitis   involv- 
ing the  upper  end   of  the   femur  various  curva- 
tures have  been  observed  in  the  neck  and  between  the  head  and  neck  of  the 
femur. 

Coxa  Vara  Due  to  Osteitis  Fibrosa:     Several  cases  have  been  reported 


Fig.  339. — Rachitic  Dwaei-. 
Femora  showing  Coxa 
Vara  (Wislar  Institute  of 
Anatomy). 


NON -TUBERCULOUS  DISEASES  OF  THE  HIP.  397 

showing  a  bending  of  the  neck  of  the  femur  in  which  the  local  condition  was 
doubtless  due  to  an  osteitis  fibrosa. 

Coxa  Vara  Due  to  Tuberculosis:  Roser's  specimen  was  considered  by 
Hofmeister  to  be  due  to  a  localized  tuberculosis.  So  far  no  specimen  has  yet 
been  found  which  shows  tuberculosis.  Very  mild  cases  of  tubercular  coxitis 
show  a  clinical  picture  of  coxa  vara. 

Coxa  Vara  Due  to  Senile  Atrophy:  An  exaggeration  of  the  decrease 
of  the  normal  angle  between  the  neck  and  the  shaft  of  the  femur  often  takes 
place,  and  at  times  the  deformity  may  be  extreme. 

Coxa  Vara  Due  to  Arthritis  Deformans:  While  this  deformity  is  rarely 
seen  during  adolescence,  occasionally  it  occurs,  and  is  hard  to  differentiate 
from  the  form  due  to  rachitis  except  by  operation. 

Coxa  Vara  Due  to  Causes  Not  Known:  Seven  specimens  are  reported 
in  which  the  histologic  findings  were  negative.  Whether  these  cases  can  be 
accounted  for  by  structural  weakness  yet  remains  to  be  proved.  Usually  the 
work  done  by  the  individual  during  the  period  of  growth  is  out  of  proportion 
to  the  strength  of  the  bone.     (Sudeck's  theory.) 

Traumatic  Coxa  Vara :  In  this  condition  there  is  present  as  a  result  of 
injury  all  the  symptoms  of  non-traumatic  coxa  vara.  The  curvature  of  the 
neck  of  the  femur  has  been  shown  by  specimens  and  x-xslj  pictures  to  be  due 
in  most  cases  to  an  epiphyseal  separation  of  the  head  of  the  femur,  and  in  a 
few  cases  to  a  fracture  through  the  neck  of  the  femur.  Of  eighty-eight  cases 
in  the  literature,  in  only  four  have  we  pathologic  or  rr-ray  proof  that  the  fracture 
was  in  the  neck  and  not  in  the  epiphyseal  line. 

Anatomy:  The  anatomy  of  this  so  frequently  overlooked  fracture  in 
young  individuals  must  now  be  considered  to  be  established  as  a  partial  or 
complete  epiphyseal  separation  in  the  majority  of  instances. 

Age:  The  age  of  the  patient  in  the  above  cases  varied  from  one  to  twenty 
years,  the  most  common  age  being  between  thirteen  and  sixteen  years,  but  it  is 
very  important  to  bear  in  mind  that  seventeen  cases  have  been  observed  between 
one  and  five  years  of  age. 

The  complete  separation  is  much  less  common  than  the  incomplete.  The 
former  produces  immediate  symptoms  and  can  be  easily  recognized  clinically; 
the  latter,  the  incomplete  separation,  gives  little  or  no  immediate  symptoms, 
which  only  develop  weeks  and  months  later,  and,  as  the  injury  may  have  been 
slight,  a  diagnosis  of  tubercular  coxitis  is  frequently  made. 

Hoffa  divides  the  cases  into  two  groups:   (i)  in  which  the  epiphyseal  sepa- 


398  ORTHOPEDIC  SURGERY. 

ration  takes  place  in  healthy  children,  and  (2)  in  which  the  fracture  occurs  in  a 
femoral  neck,  the  strength  of  which  is  weakened  by  some  pathologic  process. 
In  the  first  group  the  symptoms  all  date  from  the  injury,  in  the  second  group 
a  history  of  certain  t3rpical  symptoms  can  be  obtained  which  become 
exaggerated  after  the  injury.  Non-traumatic  coxa  vara  predisposes  to  trau- 
matic coxa  vara. 

Symptoms :  At  various  times  after  a  slight  injury  the  patient  begins  to 
complain  of  pain  in  the  hip,  and  walks  with  a  limp.  Examination  show^s  out- 
ward rotation,  adduction,  shortening,  and  slight  flexion.  Abduction  and  in- 
ward rotation  limited.  The  trochanter  is  above  Nelaton's  line.  The  symp- 
toms are  analogous  to  the  non-traumatic  variety.  X-ray  examination  show^s 
an  epiphyseal  separation  of  the  head  or  a  fracture  through  the  neck  of 
the   femur. 

Diagnosis :  In  all  cases  if  one  is  very  painstaking  there  is  always  the  his- 
tory of  trauma  to  be  obtained.  This  may  be  very  slight  and  may  have  been 
overlooked  by  the  patient;  in  other  cases  patients  give  the  history  of  falling 
from  a  considerable  height.  After  the  injury  the  patient  may  immediately 
complain  of  pain  about  the  hip,  at  times  referred  to  the  knee.  This  is  usually 
accompanied  by  slight  muscular  spasm  on  exertion,  shortening,  and  all  the 
symptoms  of  a  well-advanced  non-traumatic  case.  In  some  instances  the 
patient  is  able  to  walk  in  a  few  days  after  the  accident.  In  the  latter  class  of 
cases  there  is  probably  an  incomplete  separation  of  the  head  at  the  epiphyseal 
line,  or  an  impacted  fracture  with  bending  at  the  neck  of  the  femur.  In  a  num- 
ber of  cases  the  period  of  disability  is  short,  and,  as  a  rule,  although  there  is 
slight  deformity,  there  is  usually  a  good  functional  result.  At  this  period  the 
neck  of  the  femur  in  its  altered  angle  is  not  able  to  stand  the  strain  put  upon 
it,  and  as  a  result  there  gradually  occurs  an  increase  in  the  disability,  limp, 
pain,  actual  and  apparent  shortening,  limitation  of  abduction,  inward  rota- 
tion, and  flexion.  The  condition  continues  until  resort  is  made  to  operative 
measures. 

The  Use  of  the  x-Ray  Photograph  in  Coxa  Vara :  The  importance  of 
examining  all  cases  of  coxa  vara  and  those  having  a  doubtful  diagnosis  can- 
not be  over-estimated  as  a  means  of  differential  diagnosis.  One  having  the 
requisite  skill  in  interpreting  the  .v-ray  photograph  will  be  materially  aided 
in  making  a  positive  diagnosis  of  any  abnormal  condition  of  the  upper  end  of 
the  femur. 

Hofmeister  was  able  to  make  a  differential  diagnosis  in  six  doubtful  cases, 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  399 

the  -T-ray  photograph  showing  a  curvature  of  the  neck  in  three  cases,  and  in 
the  other  three  the  neck  was  normal.  In  seven  cases  the  diagnosis  was  con- 
firmed by  the  .r-ray  photograph.  In  taking  A'-ray  photographs  notes  should 
be  made  of  the  various  angles  used,  as  any  change  in  the  direction  of  the  rays, 
position  of  the  parts  to  be  photographed,  etc.,  will  have  a  great  bearing 
on  the  result. 

In  traumatic  cases  the  x-ray  photograph  wiU  make  the  diagnosis  certain, 
and  we  will  also  be  able  to  determine  accurately  whether  the  case  is  one  of 
epiphyseal  separation  or  a  fracture  through  the  neck.  The  photograph  will 
also  aid  materially  in  determining  the  method  of  treatment  to  be  pursued. 

Treatment:  If  seen  before  the  deformity  has  become  far  advanced,  many 
cases,  under  proper  conservative  measures,  will  recover  with  good  functional 
use  of  the  limb.  Patients  should  spend  as  much  time  as  possible  in  the  open 
air.  Any  exercise  or  position  that  throws  the  weight  of  the  body  on  the  in- 
volved part  should  be  avoided.  Constitutional  diseases  should  receive  the 
most  careful  attention.  The  tone  of  the  thigh  muscles  should  be  improved 
by  massage,  bathing,  active  and  passive  exercises,  and  particularly  should 
those  movements  be  encouraged  which  tend  to  prevent  an  increase  of  the  de- 
formity. ■  The  patient  may  be  allowed  to  go  about  with  a  properly  fitting  hip 
splint.  If  this  line  of  treatment  is  persisted  in,  and  the  cases  are  seen  early, 
many,  at  the  end  of  one  or  two  years,  will  have  a  perfect  functional  result. 

In  traumatic  coxa  vara  (epiphyseal  separation  variety)  the  treatment 
should  consist  of  extension  in  bed  for  a  period  of  about  four  weeks,  after  which 
time  the  patient  may  be  allowed  up,  in  an  ambulatory  apparatus  consisting 
of  a  plaster-of-Paris  bandage  fixing  the  hip  and  knee,  supplemented  by  a  trac- 
tion hip  splint  (^^'Tiitman) .  This  procedure  removes  the  weight  of  the  body 
from  the  involved  leg,  and  at  the  same  time  sufficient  traction  can  be  used  to 
overcome  the  muscular  spasm.  This  apparatus  should  be  worn  two  or  three 
months. 

In  traumatic  coxa  vara  (in  which  the  fracture  is  at  the  neck  of  the  femur) 
the  treatment  consists  in  forcible  abduction  and  traction,  on  the  principle  that 
the  fracture  here  is  essentially  of  a  green-stick  variety,  and  that  by  forcible 
abduction  the  deformity  in  the  neck  of  the  femur  is  removed.  While  the  limb 
is  in  this  position  of  abduction,  and  while  traction  is  being  made,  a  plaster-of- 
Paris  bandage  is  applied  from  toes  to  axilla.  After  a  period  of  from  six  to 
eight  weeks  this  bandage  is  removed  and  an  ambulatory  hip  splint  is  applied 
and  used  for  several  months.     The  after-treatment  consists  of  active  and  passive 


400  ORTHOPEDIC  SURGERY. 

exercises  and  massage.  If  these  measures  fail,  we  have  recourse  to  operative 
treatment. 

Operative  Treatment :  After  conservative  measures  have  been  unavailingly 
used  and  loss  of  function  and  deformity  have  reached  an  extreme  degree,  we 
finally  have  to  resort  to  operative  treatment  in  all  forms  of  coxa  vara. 

The  methods  of  operative  treatment  are  the  following: 

1.  Forcible  abduction.     (Traumatic  coxa  vara.) 

2.  Sub-trochanteric  osteotomy. 

3.  Resection  of  a  wedge-shaped  piece  of  bone  from  the  neck  of  the  femur. 

4.  Cuneiform  osteotomy,  or  the  removal  of  a  wedge-shaped  piece  of  bone 

from  the  shaft  of  the  femur  at  the 
level  of  the  trochanter  minor. 

5.  Linear  osteotomy  of  the  neck. 

6.  Resection  of  the  head  and  neck, 
leaving  the  trochanter  major  with 
the  shaft. 

7.  Resection  of  the  head,  neck,  and 
some  of  the  great  trochanter. 

While  all  of  the  above  operations  have 
been  performed  from  time  to  time  by  various 
Fig.  340.-METHODS  OTJ3STE0T0MY  roR     gurgeons,  I  have  found  that  the  following  can 

I,  Intertrochanteric  (Hofmeister) ;   2,  cuni-       ^e  Safely  rCCOmmendcd  : 
linear     (CodiviUa);      3,     subtrochanteric 

(Lauenstein).  I.  Sub-trochantcric  Osteotomy:  One  of 

the  simplest  means  of  correcting  this  de- 
formity is  by  sub-trochanteric  osteotomy.  This  was  first  suggested  by  Hof- 
meister, and  first  performed  by  Keetley,  in  1888.  This  operation  is  readily 
performed  by  either  the  subcutaneous  osteotomy  or  by  the  open  method, 
the  former  being  preferable.  The  osteotomy  should  be  performed  just  below 
the  trochanter  minor.  When  the  bone  has  been  divided,  it  may  be  necessary, 
on  account  of  the  contraction  of  the  abductor  muscles,  to  do  a  tenotomy.  The 
thigh  is  then  rotated  inward  until  the  foot  is  in  its  normal  position  and  the 
extremity  is  then  carried  to  a  position  of  marked  abduction.  A  plaster-of- Paris 
spica  bandage  is  then  applied  from  the  toes  to  the  axilla.  The  plaster  bandage 
is  kept  in  place  for  from  six  to  eight  weeks  and  is  then  replaced  by  a  Thomas 
hip  splint.  After  the  removal  of  the  plaster  spica  the  patient  should  be  given 
careful  massage,  passive  movements,  and  moderate  extension.  The  result 
of  this  operation  has  been  very  satisfactory. 


NON -TUBERCULOUS  DISEASES  OF  THE  HIP.  401 

2.  Cuneiform  Osteotomy:  This  consists  of  the  removal  of  a  wedge-shaped 
piece  of  bone  from  the  shaft  of  the  femur  at  the  level  of  the  trochanter  minor. 
Very  often  there  will  be  found  considerable  restriction  to  abduction,  due  to 
contraction  of  the  muscles  or  ligaments  on  account  of  the  long-continued  position 
in  adduction.  Before  proceeding  with  the  operation  it  will  be  necessary  to 
overcome  this  contraction  by  massage,  or  a  tenotomy  may  be  necessary.  The 
operation  is  performed  as  follows:  A  vertical  incision  about  three  inches 
long  is  made,  beginning  at  the  apex  of  the  trochanter  major  and  running  down- 
ward. The  bone  is  exposed,  periosteum  incised  and  reflected  to  either  side, 
and  a  wedge-shaped  piece  of  bone  is  removed  from  the  shaft  of  the  femur  at 
the  level  of  the  trochanter  minor.  The  upper  line  of  section  should  be  at  right 
angles  to  the  long  axis  of  the  shaft,  the  lower  line  of  section  should  be  in  an 
oblique  direction,  the  base  of  the  wedge-shaped  piece  should  measure  from 
I  to  I  inch.  The  line  of  section  should  not  cut  the  inner  cortical  surface  of 
the  bone.  By  not  carrying  the  line  of  section  through  the  entire  bone  the  line 
of  continuity  is  preserved  and  the  liability  of  the  slipping  by  of  fragments  is 
lessened.  The  deformity  is  then  corrected  by  abducting  the  lower  extremity, 
forcing  the  upper  fragment,  by  means  of  the  great  trochanter  against  the 
acetabulum,  using  the  lower  portion  of  the  shaft  as  a  lever. 

The  lower  extremity  being  in  a  position  of  marked  abduction,  a  plaster- 
of-Paris  spica  bandage  is  applied  from  the  toes  to  the  axilla  and  left  in  place 
about  eight  or  nine  weeks.  After  this  time  union  should  be  firm,  and  the  patient 
may  have  a  shorter  plaster  spica  applied  on  a  Thomas  splint  and  be  allowed 
to  go  about  on  crutches.  By  bringing  the  leg  into  its  proper  position  the 
deformity  is  entirely  corrected,  the  neck  of  the  femur  occupying  its  normal 
position  in  relation  to  the  shaft. 

3.  Forcible  Abduction:  This  procedure  is  often  sufficient  in  those  cases 
which  are  seen  in  the  active  state  when  the  neck  of  the  bone  is  soft  and  spongy 
and  is  capable  of  being  forced  again  into  its  normal  shape.  It  will  be  found 
that  in  a  number  of  cases  associated  with  rachitis,  occurring  in  adolescence 
especially  where  the  weight-carrying  capacity  is  suddenly  increased,  there 
occurs  this  deformity,  and  this  condition  can  often  be  corrected  by  forcible 
abduction.  This  is  done  by  bringing  the  deformed  neck  of  the  femur  against 
the  upper  border  of  the  acetabulum  while  the  head  of  the  bone  is  fixed  by  the 
capsule  and  the  shaft  is  used  as  a  fulcrum.  After  the  deformity  has  been  cor- 
rected, which  is  determined  by  the  normal  range  of  abduction,  the  extremity 

27 


402  ORTHOPEDIC  SURGERY. 

is  fixed  in  abduction  by  a  plaster-of-Paris  spica  extending  from  the  toes  to 
the  axilla,  for  a  period  of  from  six  to  eight  weeks.  After  this  the  joint  may 
be  fixed  for  a  further  period  by  a  Thomas  hip  splint. 

Coxa  Valga.    (Coxa  Abducta.) 

Coxa  valga  is  the  term  applied  to  that  deformity  in  the  neck  of  the  femur 
in  which  the  angle  formed  by  the  shaft  and  neck  is  increased.  This  condi- 
tion is  rarely  seen,  and  when  observed  is  usually  the  result  of  injury,  or  may 
be  found  associated  with  congenital  dislocation  of  the  hip.  From  an  anatomic 
view  it  is  interesting  in  comparison  with  coxa  vara.  It  may  occur  from  dis- 
use in  childhood  combined  with  traction,  as  in  the  illustration  on  page  403- 

Spontaneous  Dislocation. 

In  acute  synovitis  spontaneous  dislocation  of  the  hip  sometimes  occurs, 
there  being  usually  a  tendency  thereafter  to  repeated  luxations;  these  acci- 
dents from  infectious  synovitis,  whatever  the  cause,  being  most  frequently  the 
sequels  of  rheumatism,  typhoid  fever,  scarlatina,  etc. 

Paralytic  dislocations  from  anterior  poliomyelitis  may  be  grouped  under 
this  head,  the  dislocation  in  this  condition  being  due  to  the  flail-like  joint. 

The  treatment  of  dislocation- due  to  acute  synovitis  would  consist  in  early 
aspiration  of  the  joint  and  fixation  of  the  limb  in  an  extended  position,  and 
subsequently  the  adhesions  may  perhaps  be  broken  up.  For  the  paralytic  dis- 
location, an  operation  similar  to  the  open  operation  of  Hofta  for  congenital 
dislocation  of  the  hip  would  be  indicated,  and  good  results  from  operation 
have  been  reported  by  Carensky. 

Fracture  of  the  Neck  of  the  Femur  in  Children. 

Fracture  of  the  neck  of  the  femur — traumatic  co.xa  vara — is  not  an 
uncommon  accident,  although  until  recently  unrecognized.  Whitman  has 
observed  twenty  cases  during  the  last  nine  years. 

Fracture  of  the  neck  of  the  femur  in  childhood  has  markedly  dift'erent 
symptoms  from  fracture  in  later  life.  The  immediate  results  in  childhood 
are  much  less  disabling,  and  from  the  fact  that  the  patient  is  frequently  able 
to  walk  about  within  a  few  days  after  the  injury,  it  may  be  assumed  that  in  many 
cases  there  is  a  bending  and  breaking  of  the  neck  of  the  femur  without  an  actual 
separation  of  the  fragments.  During  the  period  of  repair  it  may  be  mistaken 
for  hip  disease. 


Fig.  341. — Coxa  Valga. 


NON-TUBERCULOUS  DISEASES  OF  THE  HIP.  405 

The  diagnosis  is  not  difficult,  and  there  is  usually  a  history  of  injury.  There 
is  a  shortening  of  the  limb,  motion  is  somewhat  restricted,  due  to  the  contraction 
of  the  muscles,  and  the  restriction  is  more  marked  in  flexion,  abduction,  and 
inward  rotation. 

While  the  immediate  effect  in  childhood  is  less  marked,  the  deformity 
tends  to  increase  in  later  years,  and  there  may  also  be  an  actual  shortening 
with  permanent  abduction. 

The  symptoms  of  joint  irritation  are  usually  combined  with  those  of  injury 
as  a  result  of  using  the  limb,  and  there  may  be  marked  sinking  of  the  neck  of 
the  femur.  In  some  cases  the  fact  that  the  leg  must  always  be  flexed  in  an 
abducted  plane  is  a  source  of  annoyance,  and  causes  much  inconvenience  in 
sitting. 

Separation  of  the  upper  epiphysis  of  the  femur  in  childhood  is  of  very 
rare  occurrence,  the  symptoms  being  elevation  of  the  trochanter,  crepitus, 
and  eversion  of  the  foot. 

Treatment. — The  first  part  of  the  treatment  would  be  the  same  as  that 
employed  in  adults,  except  that  recumbency  with  suspension  of  the  limb  at 
right  angles  to  the  body  will  sometimes  be  found  more  satisfactory.  In  this 
connection  the  subsequent  treatment  of  the  condition  is  most  important.  The 
patient  should  wear  a  traction  hip  splint  for  at  least  a  year  after  the  recovery 
from  the  fracture  of  the  femur. 

Bursitis. 

Enlargement  and  inflammation  of  the  bursas  about  the  hip-joint,  non- 
tuberculous  in  character,  occur  as  the  result  of  injury.  The  gluteal  and  iliopsoas 
bursas  are  the  ones  most  frequently  affected.  When  the  gluteal  bursa  is  inflamed, 
it  will  be  distinguished  as  an  oval,  fluctuating  mass  located  beneath  the  gluteus 
maximus  muscle.  When  the  iliopsoas  bursa  is  enlarged,  it  can  be  felt  in  Scarpa's 
triangle.     The  limb  is  flexed  and  slightly  abducted. 

In  arriving  at  a  correct  diagnosis  the  possibility  of  hydatid  cysts  of  the 
hip  should  not  be  overlooked,  and  the  existence  of  lipomas  of  the  hip  as  a 
possible  condition  should  be  borne  in  mind. 

Treatment. — The  treatment  consists  in  incision  and  drainage.  This 
should  be  accomplished  by  careful  dissection,  particular  attention  being  given 
to  avoiding  the  important  structures  in  the  vicinity. 


406  ORTHOPEDIC  SURGERY. 

Foreign  Bodies  in  the  Hip-joint. 

Wliile  foreign  bodies  in  the  knee-joint  are  of  common  occurrence,  they 
are  rarely  found  to  exist  in  the  hip-joint.  AMien  they  are  found,  they  are  of 
the  same  nature  as  those  seen  elsewhere,  and  result  from  loose  pieces  of  cartilage 
or  bone,  fibrous  exudate,  broken  osteoph3tes,  metallic  bodies  such  as  needles, 
bullets,  etc.,  and  from  h)^ertrophic  synovial  fringes.  As  the  result  of  tuberculous 
epiphysitis  I  have  obser\-ed  the  entire  fragment  h^ing  loosely  in  the  joint. 

Treatment. — If  these  foreign  bodies  cause  sufficient  annoyance  to  require 
treatment,  they  shojild  be  removed  by  incision. 


CHAPTER  VI. 
DISEASES  OF  THE  KNEE-JOINT. 

Tuberculous  ELnee-joint  Disease. 

Tuberculous  knee-joint  disease,  or  white  swelling,  is  a  chronic  lesion  of 
the  knee-joint,  beginning  usually  as  an  epiphyseal  osteitis.  As  a  rule,  the 
condition  is  localized  to  certain  portions  of  the  epiphysis,  the  femoral  or  tibial 
being  usually  the  seat  of  the  primary  osseous  focus,  although  the  lesion  may 
begin  in  the  head  of  the  fibula  or  patella.  The  disease  may  terminate  in  recovery, 
ankylosis,  or  complete  destruction  of  the  joint. 

Synonyms. — English,  Strumous  Arthritis;  Scrofulous  Disease  of  the 
Knee;  Chronic  Purulent  or  Fungous  Synovitis  of  the  Knee;  Chronic  Tubercular 
Osteitis  of  the  Knee.  German,  Scrofulose  Gelenkentziindung;  Fungose 
Arthritis;  Scrofulose  Caries;  Tuberculose  Caries.  French,  Tuberculose 
Articulaire;  Osteo-periostite ;  Tuberculose  Chronique.  Latin,  Tumor  Albus; 
Fungus  Articuli;    Caries  Sicca;    Caries  Mollis  sive  Fungosa. 

The  terms  tumor  albus  and  white  swelling  are  the  best  established,  but 
they  do  not  indicate,  as  do  the  more  modern  terms,  the  pathologic  character 
of  the  afi'ection.  For  general  use  the  term  knee-joint  disease,  here  employed, 
is  useful  and  inoffensive,  since  it  involves  no  etiologic  or  pathologic  theory. 

Etiology. 

Tuberculous  knee-joint  disease  occurs  at  all  ages,  but  is  most  frequent 
in  children  and  young  adults.  It  is  second  in  order  of  frequency,  there  being 
in  5680  cases  of  orthopedic  disease  treated  at  the  Orthopedic  Department  of 
the  University  Hospital,  Philadelphia,  104  cases  of  this  affection.  In  3820  cases 
of  tuberculous  joint  disease  treated  at  the  Children's  Hospital,  Boston,  during  a 
period  of  twenty-five  years,  the  knee-joint  was  affected  in  104  cases,  or  2.7 
per  cent.  Taking  the  combined  statistics  of  Konig  and  Gibney,  in  12 18  cases 
57.6  per  cent,  occurred  in  males.  In  704  cases  of  tuberculous  knee-jomt  disease, 
Konig  found  that  292  occurred  before  tn^enty  years,  190  between  twenty  and 
thirty  years,  93  between  forty  and  sixty  years.  Three  forms,  as  in  hip  disease, 
may  be  distinguished,  based  upon  the  primary  origin  of  the  disease — femoral, 


408 


ORTHOPEDIC  SURGERY 


tibial,  and  arthritic.  According  to  the  experience  of  Konig,  the  primar}'  synovial 
and  osseous  varieties  are  about  equally  frequent  in  youth,  but  there  are  three 
times  as  many  osseous  as  synovial  in  adults.  The  investigations  of  Willemer  * 
show  that  under  ten  years  of  age  the  disease  is  primarily  synovial  in  39  per 

cent.,  and  primarily  osseous  in  one  or  both 
articular  extremities  in  61  per  cent.;  be- 
tween ten  and  twenty,  synovial  in  49  per 
cent.,  osseous  in  51  per  cent.;  and  above 
twenty  years  of  age,  synovial  in  33  per 
cent,  and  osseous  in  65  per  cent.  The 
extent  and  peculiar  anatomic  complexity 
of  this  articulation  confer  a  peculiar  chron- 
icity  upon  all  its  diseases.  The  causes  of 
knee-joint  disease  are  both  predisposing 
and  exciting,  and  the  remarks  upon  the 
etiology  of  hip- joint  disease  apply  with 
equal  force  here.  The  predisposmg  causes 
are:  age,  sex,  heredity,  hygienic  surround- 
ings, social  condition,  and  all  those  condi- 
tions which  tend  to  deteriorate  the  general 
health.  As  exciting  causes,  traumatism 
and  cold  are  more  frequent  than  hip-joint 
disease,  and  primary  s}Tiovitis,  particularly 
in  adults,  is  much  more  frequent. 

Pathology. 

The  pathologic  lesion  is  usually  a 
chronic  epiphysitis  or  chronic  purulent 
synovitis.  The  primary  focus  may  be  in  the 
femur,  tibia,  occasionally  in  the  patella,  and 
rarely  in  the  head  of  the  fibula.  Kocher 
asserts  that  he  has  seen  primary  tuber- 
culosis of  the  semilunar  cartilages,  and 
Kummer  has  reported  a  case  of  extirpation  of  the  patella  for  primary  tuber- 
culosis of  this  bone. 


Fig.  342. — TtTBEECULOUs  Disease  of  Tibia 
AND  Fibula,  Upper  End. 


■  Deutsche  Zeitschr.  f.  Chin,"  Bd.  xxii,  p.  26S. 


DISEASES  OF  THE  KNEE-JOINT. 


409 


Tuberculous  osteitis  of  the  knee-joint  may  begin  as  a  primary  or  a  secondary 
focus.     Its  most  frequent  site  is  in  an  epiphysis,  more  frequently  occurring 


Fig.  .u.v 
a,  Caries  of  tibia  and  fibula;  J,  caries  of  tibia  and  fibula  with  ankylosis;  c,  caries  of  tibia. 


in  the  internal  condyle  of  the  femur,  next  in  frequency  in  the  head  of  the  tibia, 
then  in  the  internal  condyle  of  the  femur,  and  rarely  in  the  patella  or  head  of 
the  fibula. 


410 


ORTHOPEDIC  SURGERY. 


Konig's  report  of   66i  cases  that  came  to  operation  showed    the  position 
of  the  primary  focus  as  follows:     Primarily  osseous,  281;   primarily  synovial, 


Fig.  344. — Tuberculous  Disease  of  Knee- 
joint,  WITH  Abscess,  Lateral  View  (case  of 
Dr.  Nassau). 


Fig.  345. — S.\.ME,  Posterior  View. 


266;  and  in  29  instances  the  situation  of  the  primary  focus  could  not  be 
determined.  Of  the  osseous  form,  the  focus  was  in  the  femur  in  93  cases,  in 
the  tibia  in  137  cases,  in  the  patella  in  33  cases,  and  in  48  instances  there  were 


Fig.  346.— Exostoses  of  Femur,  Tibia,  and  Patella  from  Chronic  Synovitis. 


DISEASES  OF  THE  KNEE-JOINT.  413 

multiple  foci.  It  is  impossible  to  say  definitely  that  the  condition  was  synovial 
in  266  cases,  as  the  entire  joint  was  removed  in  only  92  instances.  Of  the 
92  cases,  the  disease  could  be  definitely  stated  to  be  primarily  osseous  in  50 
instances,  primarily  synovial  in  30  instances,  and  in  12  instances  the  position 
of  the  primary  focus  could  not  be  determined.  In  17  of  the  50  cases  the  condition 
was  primary  in  the  femur,  occurring  in  the  internal  condyle  in  7  and  in  the 
external  condyle  in  6  instances,  and  in  the  other  4  cases  the  primary  focus  occurred 
in  some  other  portion  of  the  femur.  In  17  cases  of  the  50  the  primary  focus 
was  in  the  tibia,  occurring  in  the  internal  tuberosity  in  5  and  in  the  external 
tuberosity  in  5  instances;  and  in  7  cases  the  focus  was  found  to  be  in  some 
other  portion  of  the  tibia.  The  patella  was  primarily  affected  in  5  cases.  In 
II  cases  it  was  supposed  that  the  disease  began  in  several  places  at  about 
the  same  time. 

The  original  focus  may  appear  as  a  primary  or  as  a  secondary  local  aft'ection. 
The  focus  may  have  its  origin  from  the  blood-current,  the  tubercle  bacilli  being 
carried  to  a  favorable  spot,  forming  in  time  a  gray  tubercle,  which  enlarges 
by  the  formation  of  tubercles  into  a  large-sized  focus  usually  of  a  rounded  or 
elongated  appearance.  Or  the  focus  may  have  its  origin  from  a  pre-existing 
tuberculous  focus  in  some  other  part  of  the  body.  In  this  case  a  cheesy  particle 
is  carried  by  the  blood-current  from  the  primary  focus,  usually  from  the  lung 
or  bronchial  lymph-gland,  to  the  epiphysis,  where  it  occludes  a  small  vessel, 
forming  a  bony  infarct  having  its  apex  toward  the  epiphyseal  hne  and  its  base 
in  contact  with  the  cartilage  of  the  joint. 

In  a  number  of  cases  the  original  focus  occurs  in  the  internal  condyle  and 
consists  of  a  wedge-shaped  area  having  its  base  directed  toward  the  joint  and 
its  apex  directed  toward  the  epiphyseal  line.  This  condition  is  known  as  a 
"bone  infarct,"  and  is  considered  by  W.  Miiller  to  be  due  to  a  plugging  of  an 
artery  in  the  epiphysis  by  a  tuberculous  embolus.  He  was  able  to  produce 
this  condition  experimentally  in  animals. 

Symptoms. 

The  symptoms  of  this  disease,  which  is  essentially  chronic,  can  most  suitably 
be  discussed  by  classifying  them  under  three  stages:  (i)  an  incipient  stage, 
(2)  an  acute  stage,  and  (3)  a  later  stage. 

This  classification  is  practically  identical  with  that  of  Mr.  Adams,  and 
attempts  to  give  information  as  to  the  condition  of  the  joint.  First  stage,  from 
the  onset  to  the  formation  of  pus  within  the  joint;   second  stage,  from  the  end 


414  ORTHOPEDIC  SURGERY. 

of  the  first  stage  to  the  formation  of  abscess  outside  the  joint;  third  stage,  from 
the  formation  of  abscesses  to  complete  ankylosis  or  the  death  of  the  patient. 
It  must,  however,  be  remembered  that  the  disease  may  terminate  at  any  period 
and  retrograde  changes  supervene. 

These  divisions,  correspond  to:  (i)  Localized  bone  destruction;  (2)  sup- 
puration of  joint  contents;    (3)  reparative  or  destructive  processes. 

First  Stage. — Beginning  usually  as  an  epiphyseal  osteitis,  its  onset,  as 
a  rule,  is  very  insidious.  Follov\ring  an  acute  synovitis,  some  months  later, 
when  the  acute  symptoms  have  disappeared,  there  may  remain  very  moderate 
swelling,  a  Hmp,  and  a  lessened  function  of  the  knee-joint,  in  those  of  a 
tuberculous  tendency.  This  may  be  accompanied  by  slight  pain  or  stiffness, 
attributed  to  growth  or  rheumatism.  A  limp  or  halt  in  walking,  transient,  recur- 
rent, disappearing  after  a  night's  rest,  marks  the  gradual  onset  of  this  grave 
malady.  At  this  period  examination  of  the  knee  will  show  some  swelling 
about  the  joint,  increase  in  fluid  in  the  joint,  a  lessened  distinctness  of  the 
normal  prominences  and  depressions,  with  bogginess  of  the  peri-articular 
structures,  and  perhaps  a  limp,  some  increase  in  the  circumference  about  the 
knee-joint  and  tenderness,  usually  over  the  internal  condyle.  This  condition 
may  remain  stationary  for  a  number  of  months.  Associated  with  these  there 
may  be  an  indisposition,  a  languor,  an  unnatural  inactivity,  and  an  indescrib- 
able something  included  in  the  comprehensive  word  malaise;  or  the  general 
health  may  remain  unimpaired. 

With  the  destructive  advance  of  the  local  process  the  symptoms  assume 
a  more  positive  character,  and  a  decided  limp,  intermittent  pain,  swelling  of 
the  joint,  discoloration  of  the  skin,  defective  movement  and  muscular  wasting, 
with  marked  constitutional  disturbance,  indicate  the  true  character  of  the 
morbid  affection  and  attract  attention  to  the  part. 

Lameness:  The  slight  limp  observed  in  the  early  stage  is  due  to  the  pain 
experienced  on  motion,  and  the  efforts  of  the  patient  to  diminish  the  shock 
of  the  impact  of  the  foot  upon  the  ground.  Later  the  contraction  of  the  knee, 
together  with  the  impairment  of  motion  and  complete  stiffness,  produce  a 
positive  shortening  and  interference  with  free  motion  which  are  characteristic. 
In  some  instances  an  enlargement  of  one  of  the  condyles,  usually  the  internal, 
causing  knock-knee,  adds  to  the  amount  of  disability  and  increases  the  limp. 

Pain:  The  pain  at  first  is  paroxysmal  and  shght,  of  a  dull  aching  and 
gnawing  character,  produced  or  increased  by  jarring.  Later  the  suffering 
during  the  acute  exacerbations  is  severe  and  excruciating.     This  is  somewhat 


DISEASES  OF  THE  KNEE-JOINT. 


415 


diminished  by  the  muscular  spasm,  by  which  the  joint  surfaces  are  held  rigid, 
and  motion  is  Hmited.  Tenderness  or  sensitiveness  on  pressure  is  also  present, 
the  tender  spot  being  usually  on  the  internal  condyle,  about  half  an  inch  from 
the  patellar  edge. 

Swelling:  The  tumefaction  of  the  joint  is  characteristic — shapeless, 
uniform,  obliterating  the  natural  configuration  of  the  part,  filling  the  depressions 
of  the  sides  of  the  patella — giving  an  indistinctness  of  outline  and  roughness 
of  appearance  that  cannot  be  mistaken.  Its  consistence  is  soft,  inelastic,  and 
doughy,  softer  in  some  spots  than  in  others.  Unless  the  effusion  be  large, 
the  patella  is  not  floated  up,  as  in  the  synovitis,  but  appears  fixed  in  a  soft  gelatin- 
ous mass,  or  may  even  appear  depressed  from  prominences  upon  either  side. 

Discoloration:  Instead  of  the  bright-red  color  typical  of  inflammation, 
the  skin  retains  its  natural  hue  or  loses  its  color  and  becomes  white,  whence 
it  has  derived  the  name  of 
"white  swelling."  The  surface 
is  marked  by  blue,  tortuous, 
superficial  veins.  This  is  due 
to  the  distention  present  caus- 
ing the  skin  to  be  somewhat 
anemic. 

Heat:     Elevation    of    tem- 
perature is  also  absent,  and  in 

some  cases  the  part  may  present  to  the  hand  the  impression  of  cold.  Pyrexia 
is  likewise  absent. 

Limitation  of  motion:  Among  the  earliest  positive  symptoms  the  writer 
would  lay  particular  stress  upon  this  symptom.  Preceding  even  the  symptoms 
of  local  joint  mischief,  a  limitation  of  motion,  particularly  in  forced  flexion 
and  extension,  is  characteristic  of  osteitis.  Or  the  joint  may  be  held  perfectly 
rigid  in  full  extension  or  full  flexion.  In  other  cases  there  is  a  certain  range 
of  motion  possible,  beyond  which  muscular  spasm  occurs.  This  is  due  to  a 
reflex  tetanoid  spasm,  present  in  both  the  first  and  second  stages  of  the 
disease,  but  increased  during  the  exacerbations,  and  leading  to  the  atrophy 
subsequently  observed.  It  is  most  marked  in  the  flexor  muscles  and  produces 
the  subluxations  and  complete  luxations  of  the  second  and  third  stages. 

Deformity:  The  first  deformity  to  occur  is  in  the  line  of  flexion.  This 
is  caused  by  the  fact  that  full  extension  is  necessary  in  using  the  leg  most  advan- 
tageously.    In  this  position  the  joint  surfaces  are  in  close  contact,  the  ligaments 


Fig.  347-' 


-Articular  Osteitis  (Internal  Condyle)  (Bar- 
well). 


416 


ORTHOPEDIC  SURGERY. 


are  tense  and  the  synovial  cavity  is  more  contracted  than  when  slight  flexion 
occurs.  As  swelling  of  the  condyle  occurs  accompanied  by  bogginess  of  the 
surrounding  parts,  sensitiveness  of  joint  surfaces,  and  increased  secretion  ol 
synovial  fluid,  the  result  is  flexion  with  muscular  fixation.  This  deformity 
favors  that  of  outward  rotation,  which  occurs  when  the  limb  is  flexed  and  is 
supplemented  by  the  pull  of  the  biceps  upon  the  head  of  the  fibula.  The  next 
most  frecjuent  deformity  is  backward  displacement  of  the  head  of  the  tibia;  this 

is  due  to  muscular  action  supplemented 
by  local  disease  on  the  articulating  sur- 
faces, disorganization  of  the  joint  liga- 
ments, and  by  attempts  made  at  exten- 
sion. Genu  valgum  occurs  from  primary 
increase  in  size  of  the  internal  condyle, 
from  disorganization  of  the  internal 
lateral  ligaments,  and  from  the  use  of 
the  limb  in  the  deformed  position  of 
flexion  combined  with  outward  rota- 
tion which  favors  abduction  of  the  leg 
at  the  knee.  In  tubercular  knee-joint 
disease  flexion  may  be  the  only  de- 
formity present,  or  it  may  be  combined 
'with  outward  rotation,  backward  dis- 
placement, or  genu  valgum.  A  very 
rare  deformity  in  tuberculous  knee-joint 
disease  is  hyperextension  of  the  tibia  on 
the  femur. 

Phelps  considers  the  deformities 
found  in  tuberculous  knee-joint  disease 
to  be  due  to:  (i)  A  voluntary  effort 
to  relieve  pressure  and  pain.  (2)  Involuntary  spasm  and  contraction  of  mus- 
cles, which  increase  the  deformity  by  advantage  of  the  leverage  due  to  flexion. 
(3)  Nervous  irritation  of  groups  of  muscles  due  to  localized  lesion  in  or 
about  the  joint.  (4)  Exceptional  deformities  are  produced  by  pathologic  detrac- 
tion of  bone  or  soft  parts.  (5)  Outward  rotation  of  the  leg  is  produced  by 
spasmodic  contraction  of  the  biceps  after  flexion  has  taken  place.  Flexion 
allows  lateral  and  rotary  motion  at  the  joint. 

General  condition:     Even  in  this  early  stage  the  expression  is  anxious, 


Fig.  348. — Double   Arthritis  of  the   Knee- 
joint. 


DISEASES  OF  THE  KNEE-JOINT.  417 

careworn,  and  apprehensive;  sleep  is  restless  and  disturbed,  but  without  the 
sharp  and  sudden  cry  and  pain  to  be  noted  directly;  the  appetite  is  capricious, 
the  digestion  feeble,  the  disposition  irritable,  and  in  every  way  the  general 
condition  denotes  a  local  annoyance  and  physical  distress  that  are  harassing 
and  debilitating  to  the  constitution. 

Second  Stage. — As  the  disease  progresses,  the  second  stage  is  ushered 
in  by  night-cries  and  starting  pains.  The  local  pain  changes  its  character, 
and  abnormal  movement,  with  joint  crepitation  and  subluxation,  muscular 
atrophy  and  abscesses,  indicate  the  destructive  nature  of  the  pathologic  process. 

Night-cries:  These  starting  pains  are  characteristic  of  bone  mischief, 
and  Barwell  considers  them  to  indicate  commencing  ulceration  of  cartilages. 
They  are  not  so  common  as  in  chronic  arthritis  of  the  hip,  and  they  occur  usually 
when  the  child  is  first  sinking  to  sleep.  Their  exact  nature  is  uncertain,  but 
they  probably  result  from  an  unguarded  twist,  and  the  subsequent  reflex  muscular 
spasm. 

Pain:  In  addition  to  the  acute  suffering  experienced  during  the 
exacerbations,  there  is  also  present  during  this  stage  what  Barwell  has  well 
described  as  "  intra-articular  tenderness,"  and  which  he  believes  indicates 
that  the  articular  lamella  has  given  way,  and  the  bone  cancelli  are  open  to  the 
joint.  It  is  a  soreness,  increased  upon  the  slightest  motion,  and  rendering 
the  patient  very  apprehensive. 

Abnormal  movement :  From  intra-articular  destruction  the  joint  surfaces 
admit  of  motion  in  abnormal  directions,  eliciting  also  a  grating  or  joint  crepitus 
from  friction  of  the  exposed  osseous  surfaces.  This  must  not  be  confounded 
with  the  posterior  displacement  of  the  head  of  the  tibia  upon  the  condyles  of 
the  femur,  which,  commencing  earlier,  may  at  this  stage  be  excessive  and  amount 
to  a  subluxation  or  even  to  a  complete  backward  dislocation.  These  are  often 
associated,  and  indicate  softening  or  destruction  of  the  ligaments,  and  great 
intra-articular  disorganization.  Joint  crepitus  may,  however,  not  be  elicited, 
even  though  great  destruction  exist,  from  the  luxuriance  of  the  granulations 
filling  the  joint  cavity. 

True  Lengthening  and  True  Shortening:  During  the  acute  stages,  on 
account  of  the  proximity  of  the  diseased  area  of  the  epiphyseal  cartUage,  there 
results  an  active  hyperemia  resulting  in  increased  growth.  This  may  take 
place  in  the  epiphysis  of  the  femur  or  the  tibia,  or  it  may  occur  in  both.  This 
accounts  for  the  lengthening  which  is  seen  in  the  early  stages  of  the  disease 
and  which  in  some  cases  varies  from  one-half  to  an  inch.       This  lengthening 


418 


ORTHOPEDIC  SURGERY. 


may  continue  to  be  present  throughout  the  entire  course  of  the  disease.  After 
the  disease  has  been  arrested  there  usually  occurs  ultimately  true  shortening, 
which  is  due  to  a  retardation  in  growth  of  the  side  affected,  so  that  finally  this 
side  is  shorter  than  the  well  side.  When  the  tuberculous  process  is  very  destructive 
there  occurs  considerable  shortening,  amounting  to  several  inches  in  some 
cases.     Of  course,  this  accompanies  extensive  necrosis  of  bone. 

Luesden,  in  observing  33  cases,  showed  shortening  in  2,  both  sides  equal 
in  18,  and  lengthening  on  the  diseased  side  in  13.  Berry  and  Gibney  measured 
116  cases  of  tuberculous  knee-joint  disease  with  reference  to  epiphyseal  lengthen- 
ing and  found  lengthening  in  72  cases,  or  62  per  cent.  Their  observations 
were  as  follows:  In  6  cases,  lengthening  i  inch;  in  15  cases,  lengthening  | 
inch;   in  34  cases,  lengthening  |  inch;   in  17  cases,  lengthening  \  inch. 

Taylor  in  examining  the  retardation  of  growth  of  the  limb  not  only  found 
marked  lengthening  and  shortening  of  the  femur  and  tibia,  but  also  observed 
that  there  is  general  retardation  of  growth  in  all  structures  of  the  limb  remote 
from  the  original  site.  Measurements  were  taken  in  40  cases.  He  tabulated 
his  cases  according  to  the  onset  of  joint  symptoms  into  three  classes:  (i)  those 
in  which  the  disease  had  existed  less  than  three  years;  (2)  those  in  which  the 
disease  was  at  least  three  and  less  than  five  years;  and  (3)  those  in  which  the 
affection  had  begun  more  than  five  years  previously.  His  classification  is  as 
follows : 


CLASS  I. 


Difference  (Inches). 


M. 
M. 
F. 
F. 
F. 
M. 
M. 
F. 
F. 
M. 
M. 
F. 
M. 
M. 
F. 
F. 
F. 
F. 
M. 
M. 


Right 
Left 

Right 
Left 

Right 

Left 
Right 


Right 
Left 


-i 
-i 


-i 

-i 
\ 

-i 
i 


-i 


-i 
-i 
-k 
4 
-i 
-i 


-i 
-i 
-J 
-i 
-i 
-i 
-i 
-i 
-i 
—k 
-h 


DISEASES  OF  THE  KNEE-JOINT. 
CLASS  II. 


419 


Sex. 

Age. 

Side. 

Duration, 
Years. 

Difference  (Inc 

SES). 

No. 

Limb. 

Femur. 

Tibia. 

Foot. 

Patella. 

F. 

M. 
F. 
M. 
F. 
M. 
F. 
M. 
M. 
M. 

10 
5 
3 
6 
8 
7 
7 
8 
8 

13 

Left 

Right 
Left 

Right 
Left 

Right 

3 

I 
3 
3 
4 
4 
4 
4 
4 

i 
-i 
i 
i 
i 

i 

-i 
-i 

-i 

-i 

-i 
-i 
-i 

-J 

-i 
-i 

-f 

24 

27 

28 

-i 
i                     i 

—       !         i 

-i 

i 

i 

— I 

1 

0.27 

0-33 

O.II 

— o.2g 

—0.17 

i      1 

CLASS  III. 


F. 
F. 
M. 
M. 
F. 
M. 
F. 
F. 
M. 
M. 


Right 
Left 


Right 


-2j 

I 

— I 
-i 
— 2 
—4 
—3 


Difference  (Inches). 


-1} 


-f 
-i 
-i 
-i 
-i 


-i 
-i 
-f 


Average, 


He  concluded  that  after  osteitis  of  the  knee  tlie  affected  hmb  is  nearly  always 
longer  during  the  first  two  years;  generally  longer  in  the  following  two  years, 
and  usually  much  shorter  after  seven  years'  duration,  if  the  patient  at  that  time 
had  reached  adult  growth.  This  lengthening  usually  occurs  in  the  femur 
and  very  often  is  noticeable  within  a  few  months  after  onset  of  the  disease. 

General  condition:  The  constitution  likewise  suffers.  Pyrexia,  anorexia, 
sleepless  nights,  emaciation,  and  debility  characterize  the  second  stage  of  the 
affection. 

Third  Stage. — The  third  stage  is  marked  by  repair  and  ankylosis  of  the 
joint,  or  its  total  destruction,  with  hectic,  exhaustion,  and  death  from  some 
visceral  lesion. 

Abscesses:  Though  abscesses  may  develop  earlier,  intra-articular  and 
extra-articular  suppuration  is  characteristic  of  the  third  stage.  The  pus  does 
not  find  ready  exit,  and  may  open  at  some  distance  from  the  seat  of  the  disease, 


420 


ORTHOPEDIC  SURGERY. 


or  after  separating  the  integument  from  the  underlying  connective  tissue  will 
gradually  open  and  discharge  a  quantity  of  ill-formed,  ichorous  pus,  filled  with 
flocculi. 

Upon  microscopic  examination  the  pus  was  found  by  Koch,  in  two  out  of 
four  cases,  to  contain  Bacillus  tuberculosis,  and  Schuchardt  and  Krause,  at 
Volkmann's  clinic,  and  Kanzler,  ^Nluller,  Castro  Soffia,  Roswell  Park,  and  others 
elsewhere  have  found  them  in  still  greater  relative  proportions.  The  importance 
of  the  direct  association  of  tubercular  osteitis  and  the  tubercle  bacillus  cannot 
be   overestimated.     The   course   of   abscess   formation   about   the   knee-joint, 

from  the  anatomic  peculiarity,  is  not  so  con- 
stant as  in  other  localities.  Femoral  and 
tibial  osteitis  both  tend  to  invade  the  joint. 
In  femoral  cases  in  which  the  pus  does  not 
enter  the  caA'ity  of  the  joint,  the  abscesses 
find  their  exit  in  the  inner  side,  near  the  epi- 
physeal juncture,  or  on  the  outer  and  anterior 
aspect  of  the  external  condyle  of  the  femur. 
In  tibial  cases  in  which  the  joint  is  not  pri- 
marily involved,  the  abscesses  usually  open 
upon  the  inner  side  over  the  inner  tuberosity 
of  the  bend  of  the  tibia.  In  arthritic  cases 
the  abscesses  usually  open  by  one  or  more 
sinuses  upon  the  anterior  inner  surface  of 
the  joint,  but  in  rare  instances  may  open 
posteriorly  in  the  popliteal  space,  or  burrow 
long  distances  up  or  do-rni  the  posterior 
aspect  of  the  limb  before  opening.  The 
disease,  however,  may  run  its  entire  course  without  suppuration,  or  it  may 
easily  undergo  cheesy  degeneration  and  absorption,  and  caries  sicca,  identical 
with  that  found  in  the  vertebras  and  elsewhere,  may  be  present. 


Fig.  349. — Photograph  of  Cxjeed  Case 
OF  KxEE-joiNT  Disease,  showtng 
Cicatrix. 


Recovery. 

If  the  tendency  is  to  recovery  with  ankylosis,  the  gradual  amelioration 
of  aU  the  constitutional  and  local  s}-mptoms — increased  appetite,  undisturbed 
sleep,  reduction  of  temperature,  improved  circulation  and  better  complexion, 
diminished  suppuration,  and  the  stationary  condition  of  the  local  symptoms — 
indicates  the  change  for  the  better.     Tuberculosis  in  most  cases,  with  proper 


DISEASES  OF  THE  KNEE-JOINT.  421 

care  and  by  paying  attention  to  general  treatment,  is  a  self-limited  disease. 
At  any  time  in  the  three  stages  the  process  of  repair  may  begin.  Small  tuber- 
culous areas  become  absorbed  or  encapsulated.  This  usually  occurs  by  the 
formation  of  fibrous  tissue  around  the  tuberculous  area.  Abscess  cavities 
become  replaced  by  fibrous  tissue,  caseous  material  is  absorbed,  and  small 
pieces  of  necrotic  bone  are  either  encapsulated  or  remain  at  the  bottom  of  a 
sinus  until  they  are  finally  cast  off.  Bony,  cartilaginous,  or  fibrous  ankylosis 
may  occur  at  the  articular  surfaces.  The  joint  cavity  may  be  greatly  diminished 
or  destroyed.  In  cases  that  have  considerable  deformity  if  uncorrected  anky- 
losis with  shortening,  muscular  atrophy,  and  fixation,  marks  the  cessation  of 
the  morbid  process  in  the  joint. 

Destruction. 

As  the  disease  advances,  its  destructive  process  is  marked  by  an  increase 
of  all  the  symptoms;  the  patient  becomes  apathetic,  the  hectic  is  marked  by 
greater  ranges  of  temperature,  the  evening  exacerbations  are  higher,  complete 
anorexia,  greater  restlessness;  scanty,  albuminous  urine;  profuse  night-sweats, 
and  possibly  diarrhea,  lead  to  great  exhaustion.  Notwithstanding  this  formidable 
and  melancholy  array  of  symptoms,  patients  do  not  die  of  the  joint  affection 
alone,  but  of  amyloid  disease  of  the  abdominal  viscera  (liver,  kidneys,  and 
spleen),  from  the  excessive  suppuration;  or  of  other  tuberculous  affections, 
particularly  meningitis. 

Pari  passu  with  these  several  retrograde  general  symptoms,  the  local  disease 
is  making  rapid  progress  toward  the  total  destruction  of  the  joint.  The  joint 
increases  in  size  and  softness,  the  muscles  atrophy  greatly,  the  bones  become  more 
movable  or  are  completely  luxated,  the  skin  over  the  parts  desquamates  in  large 
flakes,  and  the  sinuses  become  filled  to  overflowing  with  luxuriant  granulations. 

Diagnosis, 

The  general  diagnostic  signs  of  tuberculous  osteitis  of  the  knee-joint  are 
intermittent  lameness,  paroxysmal  pain,  general  rounded  swelling,  heat  over 
the  joint,  and  a  tender  spot  on  pressure  to  the  inner  side  of  the  patella,  with 
limitation  of  motion  and  atrophy.  The  two  last  symptoms  are  peculiarly 
significant  of  osteitis,  and  upon  them  the  writer  places  most  reliance.  Being 
a  reflex  tetanoid  spasm,  it  appears  very  early,  in  some  cases  even  before  much 
intra-articular  mischief  has  been  set  up,  or,  in  other  words,  while  the  disease 
is  still  confined  to  the  epiphysis  or  epiphyseal  cartilage. 


422  ORTHOPEDIC  SURGERY. 

Later,  the  character  of  the  swelling,  the  location  of  the  tender  spot,  and 
abscess  formation,  with  night  startings  and  cries,  render  the  diagnosis  certain. 
But  for  treatment  to  be  efficient,  it  is  essential  that  an  early  diagnosis  be  made, 
and  as  direct  aids  to  this,  great  stress  should  be  placed  upon  the  two  cardinal 
S)miptoms  before  referred  to. 

Differential  Diagnosis. 

Tuberculous  osteitis  must  be  distinguished  from  synovitis,  rheumatic 
and  suppurative  arthritis,  gonorrheal  arthritis,  arthritis  deformans,  periarthritic 
disease,  hemophilia,  acute  infectious  epiphysitis,  Charcot's  disease,  sarcoma, 
injury  to  the  knee-joint,  and  neuromimesis. 

Synovitis. — It  is  with  this  affection,  particularly  in  the  earlier  stages, 
that  tubercular  osteitis  is  most  frequently  confounded,  and  if  subacute  and 
without  effusion,  it  is  difi&cult  or  impossible  to  distinguish  between  them.  It  is 
chiefly  upon  the  character  of  the  swelling  (the  effusion)  and  the  reflex  s3miptoms 
that  the  differential  diagnosis  rests.  If  the  swelling  in  synovitis  be  large,  the 
patella,  by  pressing  upon  it,  can  be  depressed  until  it  is  felt  to  strike  against 
the  bone ;  and  on  relaxing  the  pressure  it  iloats  up  again  upon  the  fluid  within  the 
joint.  Fluctuation,  too,  may  frequently  be  detected.  In  osteitis  the  swelling  is 
soft,  inelastic,  and  doughy,  filling  the  sides  of  the  patella  and  fixing  it  immovably. 
The  localized  pain,  the  reflex  spasm  and  atrophy,  are  all  absent  in  synovitis, 
and  motion  is  often  in  the  latter  but  little  impaired. 

Acute  Rheumatic  Arthritis. — This  affection,  which  partakes  of  the 
nature  of  an  acute  synovitis,  is  characterized  by  the  sudden  onset,  the  local 
manifestations  being  preceded  by  p)Texia,  the  association  of  other  joints,  localized 
edema  about  the  affected  joints,  and  the  acute,  essentially  pyrexial  nature 
of  the  disease. 

Suppurative  Arthritis. — Acute  purulent  arthritis,  as  a  complication 
of  traumatic  infective  fever,  resembles  the  tuberculous  osteitis  in  its  destructive 
nature  and  the  presence  of  chflls,  fever,  sweating,  progressive  emaciation,  and 
loss  of  strength,  as  it  also  does  in  the  local  symptoms;  but  it  is  readily 
distinguished  from  the  latter  by  the  rapid  course,  the  association  with  traumatic 
fever,  and  by  the  character  of  the  suppuration,  which  contains  the  bacteria 
of  the  acute  infective  processes,  and  does  not  contain  the  baciUus  of  tuberculosis. 

Gonorrheal  Arthritis. — Gonorrheal  inflammation  of  the  knee-joint  very 
often  resembles  certain  cases  of  tuberculous  disease;  this  is  especially  so,  as 
the  history  is  often  concealed.     If  the  case  is  seen  during  the  acute  attack  the 


DISEASES  OF  THE  KNEE-JOINT.  423 

acuteness  of  the  symptoms,  combined  with  the  signs  of  inflammation  about 
the  joint,  high  temperature,  and  presence  of  a  gonorrheal  infection  elsewhere, 
will  contribute  toward  a  diagnosis.  In  gonorrheal  inflammation  the  induration 
about  the  joint  is  more  dense  and  the  limitation  of  motion  greater  than  in  tuber- 
culous disease.  This  limitation  of  motion  is  due  to  mechanical  causes  and 
not  to  muscular  spasm.  By  giving  an  anesthetic  the  rigidity  due  to  muscular 
spasm  will  disappear,  that  due  to  induration  about  the  joint  will  remain. 

Arthritis  Deformans. — This  affection,  particularly  that  division  known 
more  accurately  as  osteo-arthritis,  resembles  the  tuberculous  osteitis  in  the 
character  and  location  of  the  pain,  in  the  contraction  and  limitation  of  motion, 
and  the  enlargement  of  the  joint  and  the  muscular  wasting.  Moreover,  it 
may  occur  at  any  period  of  life.  It  is,  however,  to  be  distinguished  by  the 
synovial  character  of  the  tumefaction,  by  the  absence  of  fever,  rigors,  sweating, 
suppuration,  and  muscular  spasm,  and  by  the  roughness  of  the  crepitation, 
the  participation  of  other  joints,  and  its  predilection  for  mature  and  advanced 
life.     The  muscular  wasting  is  the  atrophy  of  disuse. 

Periarthritic  Disease. — Periarthritic  or  peri-articular  abscesses  and 
inflamed  bursse  are  to  be  distinguished  from  the  graver  affection  by  the  position 
and  fluctuation  of  the  swellings,  their  relation  to  the  patella,  the  entire  absence 
of  muscular  spasm,   atrophy,  joint  stiffness,   and  constitutional  disturbance. 

Hemophilia. — Very  often  this  condition  resembles  tuberculous  knee- 
joint  disease,  but  the  rapid  onset,  the  history  of  bleeder's  diathesis,  the  absence 
of  inflammatory  signs,  and  often  the  presence  of  localized  areas  of  hemorrhage 
in  other  parts  of  the  body  wiU  distinguish  the  former  from  the  latter  condition. 

Acute  Infectious  Epiphysitis. — This  is  usually  of  sudden  onset,  at  times 
there  may  be  the  presence  of  some  infectious  foci  elsewhere,  there  are  local 
inflammatory  signs,  accompanied  by  marked  constitutional  disturbances. 

Charcot's  Disease. — In  this  disease  there  develops  suddenly  an  effusion 
into  the  knee-joint;  this  is  followed  by  firm  edema,  reaching  from  the  ankle 
to  the  mid-thigh,  rapid  destruction  of  the  joint  accompanied  by  no  inflammatory 
signs,  no  muscular  spasm,  and  is  usually  preceded  by  some  disease  of  the 
spinal  cord. 

Sarcoma. — This  condition  may  be  confounded  with  tuberculous  knee- 
joint  disease,  as  its  favorite  site  is  the  lower  epiphysis  of  the  femur.  The  former 
is  more  rapid  in  growth,  is  more  localized,  the  joint  is  freely  movable,  the 
diagnosis  is  often  facilitated  by  spontaneous  fracture.  An  early  diagnosis 
can  be  made  by  means  of  the  ^-ray  photograph,  which  shows  the  destruction 


424  ORTHOPEDIC  SURGERY. 

of  bone  to  be  greater  in  sarcoma,  while  in  the  tuberculous  process  there  is 
usually  involvement  of  the  joint.  The  latter  condition  yields  more  readily  to 
treatment. 

Injury  to  the  Knee-joint. — Synovitis  accompanied  by  pain,  slight  limp, 
and  flexion  following  strains  of  the  knee-joint  are  common.  At  times  there  is  no 
history  of  injury.  The  condition  is  to  be  differentiated  from  tuberculous  condi- 
tions by  sudden  onset  and  by  it  yielding  quickly  to  treatment.  The  fact,  however, 
should  not  be  lost  sight  of  that  tuberculous  joint  disease  often  follows  apparently 
simple  synovitis  of  traumatic  origin. 

Netxromimesis. — Functional  or  hysterical  joint  disease  occurs  most 
frequently  in  young  females  of  the  upper  class,  and  usually  in  those  of  a 
pronounced  brunette  type.  This  pseudo-arthritis  can,  however,  readUy  be 
distinguished  from  the  genuine  disease  by  the  absence  of  swelling,  redness, 
atrophy,  or  muscular  spasm,  by  the  superficial  but  exaggerated  nature  of  the 
pain,  the  suddenness  of  the  attack,  and  the  fact  that  the  appetite  and  general 
condition  are  not  affected.  Moreover,  the  position  of  the  limb  is  unchanged, 
and  there  is  no  tendency  to  suppuration.  The  limitation  of  motion  disappears 
under  mental  emotion,  and  its  free  motion  is  not  then  accompanied  by  increased 
pain* 

Prognosis. 

The  prognosis  in  knee-joint  disease  is,  in  general,  more  favorable  than 
in  the  same  affection  in  the  larger  joints,  the  termination  depending  upon  the 
early  recognition,  the  social  condition  and  general  health  of  the  individual. 
A  good  nutritive  condition  is  the  most  important  point  for  a  favorable  prognosis, 
which  would  not  be  very  greatly  affected  even  by  early  and  extensive  suppuration. 
Where  treatment  is  instituted  early  and  faithfully  carried  out,  recovery  may  be 
anticipated  in  the  milder  cases.  Where  much  destruction  exists,  ankylosis 
may  supervene,  with  flexion,  subluxation,  or  permanent  distortion  of  the  joint 
in  an  unfavorable  position  for  locomotion.  In  severe  cases  flexion  is  the  rule, 
often  even  when  treated  with  the  greatest  care.  When  not  arrested  in  its  early 
stage,  the  course  is  apt  to  be  very  chronic  and  suppuration  profuse  from  the 
vast  extent  of  the  synovial  envelop,  and  the  presence  of  the  semilunar  cartilages, 
which  Ukewise  undergo  liquefaction.  In  the  severest  grades  of  the  affection 
complete  destruction  of  the  joint  results  without  ankylosis  and  renders  excision 
or  amputation  necessary.  Slight  swelling  of  the  joint,  with  great  pain  and 
early  muscular  atrophy  in  anemic  children,  but  with  little  or  no  suppuration, 


DISEASES  OF  THE  KNEE-JOINT.  425 

indicates  primary  disease  of  the  bone,  and  renders  the  prognosis  very  bad. 
In  mild  cases,  even  after  recovery,  protection  vs^ill  be  necessary  for  a  considerable 
period. 

Treatment. 

The  treatment  of  tuberculous  knee-joint  disease  may  be  classed  as 
constitutional,  conservative,  and  operative. 

Constitutional  Treatment. — This  will  include  all  therapeutic,  hygienic, 
and  other  measures  calculated  to  invigorate  the  system.  Anything  contributing 
toward  the  improvement  of  the  general  health  often  favors  spontaneous  cure 
and  lessens  the  percentage  of  operative  cases.  Hygienic  surroundings  should 
be  carefully  considered.  Patients  should  be  kept  in  the  open  air  during  the 
day  and  a  great  portion  of  the  night.  Frequent  bathing  and  plenty  of  good 
food  are  essential.  The  general  condition  should  be  improved  by  tonics,  as 
cod-liver  oU,  iodin  and  its  preparations,  hypophosphites,  iron,  arsenic,  and 
all  remedies  which  will  build  up  the  general  health. 

Mechanical  Treatment. — The  mechanical  treatment  consists  in  fixation 
and  protection  by  means  of  apparatus.  During  the  acute  stage  the  patient 
should  be  confined  to  bed,  and  at  the  same  time  some  means  of  fixation  and 
traction  should  be  employed.  Fixation  should  be  used  until  all  signs  of  local 
inflammation  have  subsided  and  any  tendency  to  displacement  is  absent. 
Protection  should  be  continued  for  a  much  longer  period. 

Fixation  is  secured  by  splints  consisting  of  plaster-of-Paris,  silicate  of  soda, 
leather,  celluloid,  hatter's  felt,  poro-plastic  felt,  papier  mache,  wood,  etc.  In 
the  application  of  these  splints  they  should  extend  from  the  ankle  to  the  perineum, 
and  whenever  possible  should  be  used  only  temporarily  until  a  proper  splint, 
which  will  fix  the  entire  thigh  and  hip-joint,  can  be  obtained. 

Plaster-of-Paris  splints  are  applied  as  follows:  the  leg  and  thigh  are 
covered  with  roller  bandages  of  sheet-wadding,  from  the  ankle  to  the  perineum, 
a  strip  of  tin  5  centimeters  in  width,  reaching  the  entire  length  of  the  leg,  is 
placed  in  the  anterior  median  line,  and  plaster-of-Paris  bandages  are  applied 
uniformly  from  ankle  to  perineum,  making  about  six  layers.  When  the  plaster 
has  set,  it  is  cut  anteriorly,  using  the  tin  strip  for  a  guide.  The  tin  strip  is 
then  removed. 

Plaster-of-Paris  splints  are  easy  to  make,  harden  quickly,  and  in  cases  of 
muscular  spasm  and  slight  flexion  successive  ones  can  be  applied  weekly  untU 
the  leg  is  straight  and  spasm  has  disappeared.     At  times  it  may  be  necessary 


426 


ORTHOPEDIC  SURGERY. 


Fig.  350.- 


-Author's  Hatter's  Felt 
Knee  Splint. 


to  apply  the  bandage  under  anesthesia,  especially  in  cases  of  long  standing 

in  which  there  is  considerable  flexion  present. 

Plaster-of-Paris  is  also  used  in  making  permanent  splints  of  silicate  of 
soda,  leather,  celluloid,  felt,  wood,  paper,  etc.,  a 
splint  of  plaster-of-Paris  being  first  made,  from 
this  a  model  of  the  leg,  and  on  this  model  is  built 
a  molded  splint  of  other  materials. 

In  all  cases  where  a  fixation  apparatus  is  used 
and  locomotion  is  employed,  protection  is  furnished 

by  means  of  axillary  crutches  and  a  high  shoe  upon  the  sound  foot,  which 

allows  the  affected  side  to  swing  clear  of  the  ground.    Better  protection  is 

afforded  by  means  of  some  splint  which  has  a  perineal  support  and  extends 

below  the  foot;  this  form  of  splint  relieves  the 

knee  from  all  jars  and  strains  during  locomotion. 
Of  the  more  elaborate  splints  used,  some  of 

which  combine  traction  with  fixation  and  protec- 
tion, are  Thomas's,  the  caliper,  Sa)Te's,  Billroth's, 

Shaffer's,   Roberts's,  the  author's,  and  Taylor's 

knee-splints. 

Thomas's  knee-splint  consists  of  an  ovoid 

iron  ring  encircling  the  thigh  at  the  perineum,  from 

which  two  iron  rods  pass  down  the  side  of  the  leg 

to  a  metal  plate  several  inches  below  the  foot,  so 

that  the  toe  of  the  diseased  hmb  may  be  fully  one 

inch  short  of  reaching  the  ground.     In  measuring 

for  the  splint,  the  length  of  the  outer  bar  is  taken 

from  midway  between  the  crest  of  the  ihum  and 

the  top  of  the  great   trochanter,  to  three   inches 

below  the  sole  of  the  foot.     The  circumference  of 

the  thigh  at  the  groin  is  taken,  allowance  being 

made  for  padding.     A  patten  must  be  worn  upon 

the  sound  limb,  and  the  apparatus  must  be  sus- 
pended by  a  strap  over  the  shoulder  of  the  sound 

side,  attached  posteriorly  to  the  ovoid  ring  and 

buckled  anteriorly.     Any  blacksmith  and  saddler 

can  construct  the  splint  from  the  following  directions:     The  upper  crescent 

is   formed   of   an   iron  ring    three-eighths   of  an   inch    in   thickness,  varying 


Fig.  351. — Author's  Celluloid 
Splint  for  Knee-joint  Dis- 
ease. 


DISEASES  OF  THE  KNEE-JOINT. 


427 


according  to  age  and  weight  of  the  patient.  It  is  nearly  ovoid  in  shape,  covered 
with  boiler  felt  and  basil  leather,  and  attached  to  the  inner  rod  at  an  angle  of 
55  degrees,  which,  when  correctly  padded,  becomes  reduced  to  45  degrees.  To 
support  the  limb,  an  apron  of  basil  leather  is  stretched  across  the  two  bars, 
and  in  the  leather  are  two  slits  for  the  insertion  of  the  bandage  by  which  it 
is  applied.  It  is  customary  in  this  country  to  secure  the  apparatus  to  the 
limb  by  two  broad  bands  of  leather,  either  buckled  or  laced  anteriorly.  Traction 
may  also  be  applied  by  utilizing  the  metal  sole-piece,  but  the  use  of  traction  is 
not  in  accordance  with  the  views  or  practice  of  the  inventor  of  the  splint.  The 
side  bars  may  also  be  made  adjustable  by  a  simple  hollow  tube  and  bar  arrange- 
ment, in  case  it  should  be  desirable  to  lengthen  or  shorten  the  splint.  The 
Thomas  splint  not  only  fixes  and  protects  the  joint,  but 
retains  it  during  the  progress  of  reduction  of  any  de- 
formity. 

The  caliper  knee-splint.    This  is  made  from  the 
Thomas  bed  splint  by  marking  two  points  on  the  end  of 
either  bar,  one  point  being  an  inch  below  the  sole,  the 
other  two  inches  below;   the  loop  is  cut  off  at  this  point 
and  the  bars  are  bent  inward  at  right  angles  by  a  suitable 
instrument.     The  bent  ends  are  fitted  into  a  tube  in  the 
heel   of   the  shoe;  the   latter  should  be  cut  to  prevent 
abrasions  of  the  heel.     The  splint  can  be  applied  after 
straightening  under  anesthesia  or  used  for  gradual  correc- 
tion.    In  walking  the  patient's  heel  is  about  one  inch 
above  the  inside  of  the  shoe.     The  leg  is  held  immovable 
by  leather  bands  beneath  the  knee  and  calf  and  graduated  pressure  is  made  just 
above  and  below  the  knee  by  bandages,  leather  bands,  or  metal  shields.     This 
splint  can  be  used  to  retain  the  corrected  position  obtained  under  anesthesia 
for  graduated  pressure  to  overcome  flexion. 

The  Sayre  knee-splint  was  designed  by  its  distinguished  inventor  to 
keep  the  knee-joint  in  a  state  of  absolute  rest  and  extend  the  parts  so  as  to 
remove  all  pressure  from  the  articular  surfaces.  As  a  fixation  splint  it  serves 
an  excellent  purpose,  but  it  can  hardly  be  admitted  at  this  time  that  it  is  capable 
of  separating  the  joint  surfaces.  What  it  probably  does,  however,  is  to  overcome 
reflex  muscular  spasm,  which  is  such  a  destructive  element  in  this  affection. 
It  consists  of  "two  sheet-iron  bands  or  collars,  connected  by  two  bars  so 
constructed  that  they  can  be  made  longer  or  shorter,  as  required.     The  bands 


Fig.  352. — Thomas  Knee- 
splint. 


428 


ORTHOPEDIC  SURGERY. 


are  about  an  inch  in  width,  have  a  joint  behind,  and  slots  and  a  pin  for  fastening 
in  front.  The  hinge-joint  at  the  posterior  portion  of  the  band  that  is  to  surround 
the  leg  is  made  by  cutting  straight  across  the  band,  and  then  fastening  the 
pieces  in  the  proper  manner  for  forming  a  joint.  The  hinge-joint  at  the 
posterior  portion  of  the  band  that  is  to  surround  the  thigh  is  made  by  cutting 
out  a  V-shaped  piece,  and  then  fastening  the  pieces  in  the  proper  manner  for 
forming  a  joint.  This  V-shaped  piece  is  removed  for  the  purpose  of  securing 
a  smaller  circle  at  the  lower  edge  of  the  band  than  at  the  upper,  which  will 
better  adapt  it  to  the  natural  tapering  shape  of  the  thigh.  The  band  which 
surrounds  the  leg  should  be  immovably  attached  to  the  side-bars.    The  band 


Sayre's  apparatus  for 
extension  at  the  knee- 
joint. 


Mode   o£    applying    the 
adhesive  plaster. 


Fig.  2SZ- 


Apparatus  adjusted. 


which  surrounds  the  thigh  should  be  attached  to  the  side-bars  in  such  a  manner 
(by  a  single  rivet  or  hinge)  that  it  can  be  tilted  about  at  pleasure,  which 
permits  the  use  of  the  instruments  when  the  leg  is  flexed  upon  the  thigh  at 
a  slight  angle.  The  bars  which  connect  these  bands  or  collars  are  divided  into 
two  pieces,  one  of  which  carries  the  cog  and  the  other  the  ratchet,  by  means 
of  which  extension  is  to  be  made.  The  ratchet  is  moved  by  means  of  a  key, 
and  in  this  manner  any  amount  of  extension  desired  can  be  readily  obtained."* 
The  Billroth  splint.  This  splint  is  frequently  used  in  overcoming 
persistent  deformity.  During  its  use  patients  should  be  kept  under  observation, 
as  it  is  liable  to  cause  sloughs.    All  points  of  pressure  should  be  carefully  padded. 


■Sayre:  "Orthop.  Surg.,"  ed.  1S83,  p.  210. 


DISEASES  OF  THE  KNEE-JOINT. 


429 


and  in  addition  pads  of  felt  or  similar  material  should  be  placed  iji  front  of 
the  condyles  of  the  femur  and  behind  the  upper  end  of  the  tibia.  A  plaster- 
of-Paris  bandage  is  applied  from  the  toes  to  the  groin  and  is  made  purposely 
thick  in  the  popliteal  region.  In  the  bandage  two  joined  iron  strips  attached 
to  broad  tin  plates  are  incorporated  at  the  knee-joint,  the  point  of  junction 
of  the  strips  being  just  above  and  in  front  of  the  joint.  After  the  plaster  has  set, 
the  front  over  the  knee  is  cut  out  and  a  transverse  cut  made  in  the  posterior 
aspect.  By  inserting  vi^edges  of  increasing  sizes  the  edges  of  the  cut  are 
separated  and  the  knee-joint  gradually  extended.     This  splint  has  a  slight 


r 

IQj|\   r^^^j-        jTrr 


Fig.  354. — Shaffer's  Knee  Splint. 

tendency  to  overcome  any  subluxation  that  may  be  present.  On  account  of  the 
great  pressure  which  it  exerts  its  use  should  be  carefully  watched. 

The  Shaffer  splint.  The  ingenious  apparatus  of  Shaffer  (Fig.  349)  is 
designed  to  apply  the  desired  force  directly  to  the  head  of  the  tibia,  throwing 
the  same  forward  and  downward  by  a  simple  movement.  The  force  applied 
to  overcome  the  muscular  contraction  is  in  a  direct  line  with  the  deformity, 
and  the  effect  is  to  reheve  joint-pressure  and  correct  the  deformity  simultaneously. 
The  apparatus  is  thus  described:* 

"It  consists  of  three  parts — the  thigh,  leg,  and  intermediate.  The  first 
two  are  secured  to  the  limb  by  adhesive  plasters,  which  are  attached  at  the 
points  A  A.     Extension  is  made  with  a  key  at  the  extension  rod  proper  at  B. 


*  "On  Refle.x  Muscular  Contraction  and  Atrophy  in  Joint  Disease,"   "Archives  of  Clin.  Surg.,"  June,  iS 


430  ORTHOPEDIC  SURGERY. 

The  joints  at  c  and  d  move  upon  pivots,  and  as  the  extremities  of  the  apparatus 
are  secured  by  their  adhesive  straps  at  a  a,  the  joint  d  moves  forward  and  down- 
ward, describing  a  circle,  the  radius  of  which  is  the  bar  E.  Pressure  is  thus 
made  directly  upon  the  head  of  the  tibia  by  the  band  f,  and  this  can  be  very 
greatly  augmented  by  using  the  extension  rod  at  G,  which  further  relieves  the 
joint  of  pressure  by  additional  extension  in  the  position  already  acquired  by 
the  preliminary  extension  of  the  rod  b.  h  is  an  accommodation- — not  properly 
an  extension  rod — which  glides  forward  as  the  extension  is  applied  at  b.  As 
soon  as  the  leg  is  thrown  sufficiently  forward  the  accommodation  rod  is  secured 
by  a  slide,  and  an  extra  turn  of  the  key  at  b  and  G  leaves  the  joint  free  from 
pressure,  and  with  adequate  extension  applied  directly  to  the  contracted  flexors. 
The  thigh  and  leg  bands  at  h  and  i  move  upon  pivots,  so  that  they  adjust 
themselves  readily  to  any  position,  and  at  k  there  is  an  arrangement  by  which 
the  curved  bar  l  may  be  adjusted  to  suit  the  requirements  of  the  extension  rod 
B.  The  bars  M  and  o  are  secured  to  the  thigh  and  leg  parts  by  double  rivets. 
Through  the  buckles  at  p  p  p  webbing  straps  (padded)  are  passed,  producing 
counter-extension  in  addition  to  that  secured  by  means  of  the  adhesive  straps." 

This  apparatus  gives  most  perfect  fixation  and  extension  to  the  joint, 
relieving  intra-articular  pressure,  overcoming  muscular  contraction,  and  correct- 
ing deformity.  It  requires  skill  in  its  application  and  constant  attention  on 
the  part  of  the  surgeon  or  attendant,  and  is  not,  therefore,  adapted  for  general 
extensive  use. 

The  Roberts  brace.  The  same  may  be  said  of  the  Roberts  *  brace, 
which  is  the  one  the  writer  prefers  and  employs  where  the  patient  or  institution 
can  afford  the  more  expensive  apparatus.  It  consists  of  two  light  steel  troughs 
padded  or  coated  with  rubber,  that  are  firmly  secured  to  the  limb  by  encircling 
bands  of  surgical  webbing,  affording  absolute  fixation  to  the  joint  when  the 
extending  rods  are  locked  after  adjustment.  Three  ratchet  extension  bars 
arranged  in  the  form  of  a  triangle  are  placed  posteriorly,  corresponding  to 
the  long  axis  of  the  limb.  This  enables  the  surgeon  to  produce  extension, 
to  overcome  flexion  and  the  tendency  to  the  production  of  deformity,  the 
extension  rod  b  acting  directly  upon  the  head  of  the  tibia  and  parallel  with 
the  line  of  contraction  of  the  flexor  group  of  muscles,  and  not  low  down  on  the 
tibia,  as  in  the  popular  Stromeyer's  splint,  and  all  splints  constructed  upon 
that   faulty   mechanical    principle.      Moreover,   force  applied    below   estab- 

*  "Trans.  Med.  Soc.  of  Penna.,"  1SS4,  p.  40S. 


DISEASES  OF  THE  KNEE-JOINT. 


431 


lishes  a  fulcrum  at  the  surface  of  the  diseased  joint,  thereby  increasing  the 
disease.  In  this  splint  the  long  extension  rod  c  is  used  only  as  a  compensating 
bar,  adjusting  the  angle  of  the  splint  to  the  angle  of  the  flexion  of  the  limb. 
The  power  for  restoring  the  head  of  the  tibia  and  overcoming  the  spasmodic 
contraction  of  the  flexor  muscles  is  applied  with  moderation  directly  in  the 
axis  of  their  contraction.  Through  the  extension  bar  B  (Fig.  350)  the  head 
of  the  bone  describes  in  its  restoration  the  arc  of  a  circle.  The  com- 
pensating bar  in  correcting  the  angle  of  flexion  carries  the  limb  through 
the  arc  c  to  D,  having  a  center  in  the  end  of 
the  femur.  Mechanically  this  arrangement  of  force, 
as  Dr.  Roberts  remarks,  corrects  the  deformity 
and  relieves,  by  extension,  the  reflex  spasm  of  the 
flexor   muscles    without  crowding  together    the    dis- 


FiG.  355. — Roberts's  Exten- 
sion Knee  Splint. 


Fig.  356. — Roberts's  Extension  Knee  Splint  Applied. 


eased  joint  surfaces,  or  aiding  in  subluxating  the  head  of  the  tibia,  as  would 
be  the  case  should  the  limb  proper  be  used  as  the  long  arm  of  our  lever, 
with  the  insertion  of  the  hamstring  tendons,  instead  of  the  normal  center  of 
motion  of  the  joint,  as  the  center  of  motion  of  the  splint.  Supplementing  the 
direct  extension  upon  the  contracted  muscles,  another  bar  d  has  been  added 
to  aid  in  steadying  the  joint  and  relieving  intra-articular  pressure.  The  splint 
acts  upon  the  limb  through  adhesive  plaster  applied  above  and  below  the  joint, 
to  which  surgical  webbing  has  been  attached.  This  webbing  is  firmly  secured 
to  the  counter-extending  band  f,  and  to  the  extension  rod  g,  affording  a  means 
of  direct  extension  always  corresponding  to  the  angle  of  flexion.    The  extension 


432  ORTHOPEDIC  SURGERY. 

bars  are  controlled  by  a  key  and  ratchet  movement,  held  in  place,  after  adjust- 
ment, by  a  small  ring  and  pin. 

This  splint  meets  all  the  indications  better  than  any  apparatus  with  which 
the  writer  is  familiar,  and  enables  the  patient,  by  means  of  crutches,  to  enjoy 
all  advantages  of  exercise  in  the  open  air.  It  overcomes  reflex  muscular  spasm, 
relieves  joint  pressure  by  making  extension  in  the  line  of  deformity,  and  fixes 
the  articulation  in  the  most  favorable  position  for  recovery.  The  author's 
knee  splint  is  similar  to  Roberts's,  but  simpler  in  construction. 

A  very  useful  walking  splint,  and  one  highly  recommended  by  Bradford 
and  Lovett,  is  one  similar  to  that  described  under  hip  disease  as  Taylor's 
protection  splint.  It  consists  of  a  long  outside  bar  provided  with  a  perineal 
band  above,  a  lock-joint  at  the  knee  that  can  be  set  at  any  angle,  and  an  extension 
bar  below  the  foot.  Application  of  the  splint  is  made  with  adhesive  plasters 
and  surgical  webbing,  attached  above  to  the  splint  and  below  to  the  extension 
bar.  The  knee-joint  on  the  splint  is  set  at  an  angle  corresponding  to  the  angle 
of  deformity,  extension  is  made,  and  the  splint  secured  to  the  limb  by  leather 
lacings. 

Supplementary  Treatment. — In  connection  with  mechanical  treatment 
there  are  many  local  measures  in  use  which  often  prove  of  great  value.  Some 
of  the  local  measures  are :  Tincture  of  iodin,  cantharidal  collodion,  Paquelin 
cautery,  :r-ray,  compression  with  adhesive  plaster,  mercurial  and  silver  ointments, 
injections  of  iodoform  emulsion,  carbolic  acid,  and  passive  congestion. 

Tincture  of  iodin  may  be  used  locally  in  repeated  applications.  Tincture 
of  cantharides  may  be  used  in  the  form  of  cantharidal  collodion,  cantharidal 
plaster,  or  the  tincture  itself  may  be  used. 

The  Paquelin  cautery  may  be  used  either  locally  on  the  skin  or  in  more 
severe  cases  can  be  introduced  directly  into  the  bone  tissues  softened  by  osteitis. 
This  has  a  beneficial  effect  by  promoting  the  development  of  cicatricial 
granulation  tissues. 

The  use  of  the  x-rays  has  of  late  been  tried  with  beneficial  effect  and  does 
good  by  increasing  the  amount  of  blood  to  the  part,  thereby  stimulating  granula- 
tion tissue,  which  in  time  forms  cicatricial  tissue. 

In  some  cases  much  improvement  is  obtained  by  compression  with  adhesive 
plaster,  flannel,  and  rubber  elastic  bandages. 

The  following  ointments  are  used  by  the  author:  Ichthyol  ointment, 
40  per  cent,  strength;  compound  iodin  ointment;  mercury  and  belladonna 
ointment     (ung.     bellad.    ^],    ung.     hydrarg.     oiij).      Billroth    recommended 


DISEASES  OF  THE  KNEE-JOINT.  433 

a  Strong  ointment  of  nitrate  of  silver  (oj  to  5j)  rubbed  into  the  joint.  The 
injection  of  iodoform  emulsion  has  often  been  followed  by  very  favorable  results. 
In  cases  of  moderate  synovitis  the  fluid  may  disappear  rapidly  and  permanently. 
Improvement  usually  follows  the  first  injection;  if  none  occurs  after  the  fourth 
or  fifth,  the  injections  should  be  discontinued.  A  sterilized  aspirating  needle 
is  used.  The  point  of  injection  should  be  at  the  outer  side  of  the  patella  at 
its  upper  border  or  over  the  most  prominent  portion  of  the  swelling.  The 
fluid  in  the  joint  is  withdrawn  and  5  to  10  c.c.  of  a  10  per  cent,  sterilized  emulsion 
of  iodoform  in  glycerin  or  oil  is  injected  according  to  the  age  of  the  patient. 
The  wound  is  sealed  by  collodion  or  appropriate  sterile  dressing.  Injections 
may  be  repeated  every  ten  to  fourteen  days.  Konig,  after  washing  out  the  joint 
with  a  2  per  cent,  solution  of  carbolic  acid,  injects  a  5  per  cent,  of  the  same 
solution.     He  claims  very  good  results  from  its  use. 

Passive  congestion — Bier's  method.  This  consists  in  applying  a  rubber 
bandage  above  the  knee-joint  sufSciently  tight  to  check  the  venous  flow,  and 
from  the  toes  to  just  below  the  knee  a  tight  flannel  bandage  is  applied.  This 
method  is  used  for  one  to  two  hours  until  it  is  well  borne,  and  then  may  be 
used  all  day.  It  should  be  removed  at  night.  The  injection  of  iodoform 
emulsion  may  be  used  in  connection  with  it.  Its  use  is  contraindicated  by  the 
presence  of  abscesses.  It  is  supposed  to  do  good  by  increasing  the  amount  of 
blood  to  the  part,  thereby  forming  granulation  into  fibrous  tissue.  Mikulicz 
claims  for  it  the  special  advantage  of  rapid  subsidence  of  the  pain  in  very  painful 
joints.  At  present  its  use  is  limited  and  it  should  be  employed  only  under 
careful  observation. 

Treatment  of  Complications. 

The  complications  requiring  special  treatment  are  deformity  and  abscess. 

Deformity. — Flexion  of  the  knee  is  an  early  and  persistent  complication  of 
knee-joint  disease.  It  occurs  at  two  separate  periods  of  the  aft'ection,  as  a  pain- 
ful symptom  of  the  early  acute  stage,  and  as  an  insidious,  painless  complication 
of  the  later  stage.  The  means  required  for  straightening  the  knee  wiU  difl'er  at 
these  two  periods,  and  may  be  classified  into:  (i)  Repeated  fixation  in  plaster- 
of-Paris  splints.  (2)  Traction,  (a)  Recumbent,  (&)  ambulatory.  (3)  Gradual 
forcible  extension.  (4)  Rapid  forcible  extension.  (5)  Supracondyloid  osteot- 
omy.    (6)  Resection  of  the  knee-joint. 

I.  Repeated  fixation  in  plaster-of-Paris  splints.  A  very  simple  and 
inexpensive  way  of  correcting  the  deformity  is  by  means  of  plaster-of-Paris  ban- 


434  ORTHOPEDIC  SURGERY. 

dages  applied  at  intervals  of  one  week.  These  bandages  should  be  applied  from 
the  toes  to  the  groin.  All  bony  prominences  should  be  protected ;  slight  correction 
that  does  not  cause  pain  may  be  used.  It  will  be  found  that  in  applying  successive 
bandages  the  muscular  spasm  has  decreased  to  such  an  extent  that  full  extension 
is  possible  without  causing  pain.  During  the  process  of  extension  the  patient 
must  not  bear  any  weight  on  the  foot,  and  very  often  the  patient  will  improve 
more  rapidly  if  kept  at  complete  rest  in  bed. 

2.  Traction.  Traction  should  always  be  made  in  the  line  of  the  deformity, 
(a)  Recumbent  traction  by  weight  and  pulley,  which  can  be  applied  below  the 
knee  by  adhesive  plaster.  The  leg  should  be  supported  upon  a  pillow,  a  posterior 
angular  splint,  or  may  be  suspended  in  a  suitable  apparatus.  The  foot  of  the 
bed  should  be  raised  to  secure  counter-extension.  The  weights  used  should 
be  very  light,  only  sufficient  to  steady  the  limb.  As  the  muscular  spasm  and 
flexion  decrease  the  limb  can  be  gradually  placed  in  full  extension.  After  all 
sensitiveness  and  pain  have  ceased  the  patient  may  be  allowed  up  on  crutches 
after  some  ambulatory  apparatus  has  been  applied,  (b)  Ambulatory  traction 
may  be  used  from  the  beginning.  One  of  the  best  traction  splints  is  the  one 
modified  by  Dr.  Lovett.  The  splint  consists  of  two  uprights,  one  inside  and 
one  outside,  joined  at  the  knee.  On  the  outer  upright  at  the  top  is  an  arm  to 
carry  a  perineal  band  and  to  furnish  counter-extension.  At  the  bottom  of  the 
upright  is  a  windlass,  to  which  may  be  attached  the  extension  straps  running 
from  the  knee  downward.  Counter-extension  is  also  furnished  by  adhesive 
straps  attached  to  the  top  of  the  splint.  At  the  knee,  by  means  of  a  disk  and 
screws  which  control  the  various  holes,  the  splint  can  be  set  and  held  at  any 
angle.  The  splint  is  held  in  place  by  leather  bands  passing  around  the  thigh 
and  calf.  The  splint  can  be  used  with  crutches  and  a  raised  sole  on  the  other 
foot.  It  can  be  used  as  a  simple  walking  splint  without  crutches  and  with  a 
slight  high  sole  on  the  sound  foot;  and  during  convalescence  the  windlass  and 
extension  can  be  omitted,  the  ends  of  the  uprights  fitted  to  a  shoe,  and  the 
splint  used  for  protection. 

H.  L.  Taylor  uses  a  traction  apparatus  in  which  extension  and  counter- 
extension  are  made  by  adhesive  plaster  which  is  attached  to  straps.  This  is 
surrounded  by  a  plaster-of-Paris  splint,  to  the  ends  of  which  the  traction  straps 
are  attached.    Crutches  and  a  high  sole  on  the  sound  side  complete  the  apparatus. 

The  splints  of  Dr.  Roberts  and  Dr.  Shaffer,  described  previously,  are  also 
used.  Whatever  splint  is  used,  it  should  be  such  that  traction  can  be  made  in 
the  line  of  the  deformity,  overcoming  the  flexion  and  subluxation  without  estab- 


DISEASES  OF  THE  KNEE-JOINT.  435 

lishing  a  fulcrum  at  the  surface  of  the  diseased  joint,  which  is  always  the  case 
when  force  is  applied  at  a  distance  below  the  insertion  of  the  resisting  flexor 
muscles. 

3.  Gradual  forcible  extension.  This  may  be  applied  by  means  of  the 
Thomas  knee  splint,  the  Billroth  splint,  Stillman's  sector  splint,  or  the  caliper 
splint.  In  employing  the  Thomas  knee  splint  to  correct  deformity,  the  roller 
bandage  is  firmly  applied  in  front  of  the  thigh  and  knee  and  behind  the  calf. 
The  more  firmly  these  are  applied,  the  greater  the  pressure  that  is  exerted,  and 
great  care  must  be  taken  lest  an  acute  exacerbation  be  excited  from  improperly 
applied  force. 

The  Billroth  splint  is  a  simple  and  very  efficient  method  of  applying  plaster- 
of-Paris  extension.  It  consists  of  a  plaster  bandage  applied  to  the  limb,  in 
which  at  the  knee  are  incorporated  two  hinged  iron  strips.  The  bandage  is 
made  thicker  under  the  knee,  is  allowed  to  harden,  and  a  window  is  cut  above 
over  the  knee,  and  below,  beneath  the  knee,  a  transverse  division  of  the  plaster 
is  made.  Into  this  slit  wedge-shaped  pieces  of  cork  of  increasing  size  are  daily 
inserted,  until  the  knee  is  straight.  Extension  must  not  be  begun  before  twenty- 
four  hours.  The  writer  is  personally  familiar  with  its  application  in  Prof. 
Billroth 's  clinic  in  Vienna,  where  its  excellence  has  been  fully  tested  in  many 
cases.  The  force  exerted  is  great,  and  the  splint  must  be  carefully  watched. 
There  is  no  better  appliance  for  public  charity  use.  In  both  the  Thomas  splint 
used  for  extension  and  the  Billroth  splint  the  power  is  applied  upon  the  erron- 
eous mechanical  principle  of  the  popular  Stromeyer  splint,  i.  e.,  the  power  is 
applied  low  down  on  the  tibia,  establishing  a  fulcrum  at  the  surface  of  the 
diseased  joint  and  exerting  injurious  pressure  upon  the  diseased  surfaces.  Still- 
man's  sector  splint  is  open  to  the  same  objection.  For  retention  after  extension, 
the  sector  splint  of  the  author  will  be  found  useful  and  inexpensive.  Instead 
of  the  simple  free,  or  locked  joint,  a  sector  is  added  to  one  arm  of  the  joint, 
which  enables  it  to  be  refixed  at  any  angle  by  a  set-screw.  A  large  leather 
knee-pad  secured  by  straps  and  pins  extends  and  fixes  the  knee-joint.  A  con- 
siderable amount  of  pressure  may  likewise  be  exerted.  The  cut  (Fig.  454) 
sufficiently  explains  the  details.     The  caliper  splint  has  been  described  above. 

4.  Rapid  forcible  extension — redressement  force.  This  should  not  be 
employed  in  the  early  stages  or  in  acute  cases,  but  where  firm  fibrous  ankylosis 
exists,  this  wiU  be  found  to  be  the  most  efficient  method  of  overcoming  deformity- 
Manual  force  will  be  sufficient  in  the  majority  of  cases,  and  powerful  mechanical 
appliances  should  be  avoided  if  possible.     The  knee  should  first  be  forcibly 


436  ORTHOPEDIC  SURGERY. 

flexed  and  then  forcibly  extended.  All  contracted  tendons  and  fascias  should 
be  freely  divided,  open  incision  being  the  best  method  in  this  situation.  A  free 
incision  across  the  popliteal  space  allows  ample  inspection,  and  in  this  manner 
rupture  and  division  of  the  popliteal  artery  may  be  avoided.  Fracture  of  the 
femur  and  separation  of  the  epiphyses  may  also  be  avoided  with  proper  care, 
but  should  they  occur,  they  do  not  necessarily  increase  the  gravity  of  the  prog- 
nosis, and  their  cure  will  be  effected  by  the  subsequent  fixation  requisite  to 
treatment.  If  a  mechanical  appliance  is  required,  the  best  will  be  found  to  be 
Goldthwait's  genuclast.  Its  action  is  thus  described:  Pressure  forward  on  the 
head  of  the  tibia  is  exerted  by  turning  the  handle;  this,  by  means  of  a  screw- 
force,  pushes  the  plate  forward,  working  through  the  band.  The  calf  muscles 
protect  the  artery  and  nerve  from  injurious  pressure.  Counter-pressure  is 
secured  by  means  of  leather  straps,  which  are  passed  respectively  over  the  knee 
and  leg,  protected  by  a  thick  layer  of  saddler's  felt.  Several  straps  will  be 
needed  at  the  knee  to  prevent  loss  of  counter-pressure  as  the  limb  is  made 
straighter.  Another  strap,  under  the  leg,  secures  the  lower  part  of  the  leg. 
The  side-bars,  bands,  and  plate  of  the  apparatus  should  be  of  strong  steel.  After 
correction  the  limb  from  toes  to  upper  thigh  should  be  well  padded,  especially 
around  the  knee,  when  considerable  swelling  may  take  place,  by  cotton  batting 
or  sheet  wadding,  and  a  plaster-of-Paris  bandage  applied,  the  limb  being  held 
in  the  corrected  position  untU  the  plaster  has  set. 

5.  Supracondyloid  Osteotomy.  When  the  deformity  present  cannot  be 
corrected  by  mechanical  means  linear  osteotomy  just  above  the  condyle  may 
be  performed.  WhUe  this  procedure  retains  in  the  joint  any  motion  that  may 
be  present,  it  does  not  correct  the  faulty  angle  formed  by  the  articulating  surface. 

6.  Excision.  This  is  performed  in  cases  when  ankylosis  is  complete.  The 
technic  of  this  operation  will  be  described  below. 

Authorities  differ  in  regard  to  the  relative  value  of  these  last  two  operative 
procedures.  Poinset  believes  resection  preferable,  for  the  reason  that  the 
removal  of  all  diseased  tissue  obviates  the  possibility  of  subsequent  inflamma- 
tion, and  has  recorded  seventy-seven  collected  cases,  with  a  mortality  of  8  per 
cent.  He  regards  the  operation  as  entirely  free  from  danger  in  patients  under 
fifteen  years  of  age.  Jacobson,  on  the  other  hand,  thinks  excision  should  be 
abandoned  for  the  better  operation  of  osteotomy,  strongly  urging  caution  in 
rapidly  and  completely  straightening  a  knee-joint  which  has  long  been  the  seat 
of  a  bony  ankylosis  in  a  bad  position,  the  dangers  being  pressure  upon  the 
popliteal  vein  and  tetanus  from  stretching  of  the  contracted  popliteal  fascia  and 


DISEASES  OF  THE  KNEE-JOINT. 


437 


the  popliteal  nerves.  The  best  methods  would  appear  to  be  forcible  manual 
extension,  forcible  mechanical  extension,  osteotomy,  and  resection,  in  the  order 
named.  Resection  should  be  reserved  for  bony  ankylosis  in  adults,  and  should  be 
abandoned  for  osteotomy  in  all  cases  when  possible.  The  operative  procedure, 
surgical  technic,  etc.,  wUl  be  found  described  in  works  upon  general  surgery. 

When  operative  measures  are  declined,  an  apparatus  to  overcome    the 
shortening  will  assist  the  patient  in 
walking. 

Abscess. — Under  efficient  me- 
chanical treatment  suppuration  and 
fistulas  are  less  frequent,  but  when 
abscesses  occur  they  may  be  treated 
on  the  same  general  plan  as  hip  ab- 
scesses. Small  localized  abscesses  may 
be  allowed  to  remain  with  the  hope 
of  reabsorption,  or  to  open  spontan- 
eously while  the  limb  is  firmly  fixed 
in  some  retaining  apparatus,  after  the 
method  recommended  by  Volkmann 
and  Billroth.  Large  burrowing  ab- 
scesses should  be  freely  opened  under 
full  antiseptic  precautions,  but  small 
circumscribed  ones  may  be  allowed  to 
burst  spontaneously.  If  the  accumu- 
lation of  fluid  be  great,  it  should  be 
removed  by  aspiration  under  the  most 
rigid  antiseptic  precautions.  The 
general  management  of  abscesses  will 
be  the  same  as  described  under  ab- 
scess in  hip  disease.  Even  after 
numerous  abscesses  have  formed  and 

discharged,  spontaneous  recovery  may  follow.  Abscess  formation  occurs  in  about 
one-third  of  all  cases.  It  usually  results  in  those  cases  in  which  treatment  has 
been  delayed  or  faulty.  Its  frequency  is  shown  by  the  statistics  of  Gibney,  47 
per  cent.;  and  Konig,  51  per  cent. 

Expectancy. — As  long  as  the  general  condition  of  the  patient  remains 
good,  an  attempt  may  be  made  to  secure  recovery  by  rest  and  fixation  and  the 


Fig.  357. — Orthopedic  Resections  for  Ankylosis 
FOLLOWING  Knee-joint  Disease. 


438  ORTHOPEDIC  SURGERY. 

use  of  antiseptic  injections.  The  sinuses  should  be  irrigated  daily  with  a  i  :  2000 
bichlorid  solution,  to  be  followed,  if  the  sinus  be  free,  with  injections  of  pure 
peroxid  of  hydrogen,  washed  again  with  the  bichlorid  solution,  and  injected 
finally  with  from  i  to  4  drams  of  emulsion  of  iodoform  in  sterilized  sweet  oil 
in  the  strength  of  10  per  cent.,  after  which  a  full  antiseptic  dressing  should  be 
applied,  and  the  limb  secured  in  a  plaster-of -Paris  cast  or  other  apparatus. 
Under  this  plan  of  treatment  the  discharge  may  lessen,  the  sinuses  close,  and 
ultimate  recovery  quickly  ensue.  Some  of  the  injections  formerly  used  may 
still  be  prescribed  with  benefit,  as  solutions  of  nitrate  of  lead,  potassium  per- 
manganate, or  dilute  carbolic  acid  (2  to  5  per  cent.). 

The  disintegration  and  discharge  of  necrotic  tissue  may  be  hastened  by 
the  use  of  solutions  of  nitric  acid  (3  per  cent.),  with  or  without  the  addition 
of  active  solutions  of  pepsin.  After  these  preparations  have  been  allowed  to 
remain  in  the  sinuses  for  twenty  or  thirty  minutes,  the  cavities  must  be  irrigated 
with  bichlorid  solution  to  remove  the  digested  tissue. 

Operative  Treatment. — In  cases  that  become  progressively  worse  after 
conservative  measures  have  been  tried  unsuccessfully;  in  those  that  have,  from 
the  beginning,  been  very  extensive;  in  those  in  which  there  are  large  abscess 
cavities  connecting  with  the  joint,  showing  mixed  infection,  and  which  are 
not  draining  properly,  and  in  those  in  which  the  general  health  is  failing  rapidly, 
operative  measures  are  to  be  resorted  to.  These  may  be  considered  under  the 
three  following  heads:    (i)  Arthrectomy;   (2)  resection;    (3)  amputation. 

I.  Arthrectomy,  or  erasion,  consists  in  laying  open  the  joint  and  by  means 
of  the  bone  curet  removing  all  of  the  diseased  tissue,  irrigating  the  joint  freely 
with  bichlorid  solution  during  the  operation,  passing  drainage-tubes  through 
the  joint,  dressing  the  wound  antiseptically,  and  immobilizing  the  joint.  As  a 
substitute  for  excision,  this  operation  has  been  employed  by  many  surgeons, 
both  at  home  and  abroad,  and  ofifers  advantages  over  the  latter  operation  in 
children  and  where  the  disease  is  not  extensive,  where  thorough  removal  can 
be  accomplished,  and  especially  where  the  synovial  membrane  alone  is  affected. 
Its  chief  advantages  are  that  it  does  not  usually  prevent  the  after-growth  of  the 
limb  and  does  not  cause  complete  ankylosis.  The  operation,  in  brief,  is  as 
follows:  Hemorrhage  is  controlled  by  an  Esmarch  bandage  and  tourniquet 
above  the  knee;  the  joint  is  exposed  by  a  transverse  curved  incision  with  its 
convexity  downward.  The  incision  may  be  made  above,  below,  or  through 
the  patella.  The  synovial  membrane  should  be  dissected  out  and  all  foci  in 
bone  should  be  carefully  removed  by  means  of  gouge  and  chisel.     All  infected 


DISEASES  OF  THE  KNEE-JOINT. 


439 


material  should  be  removed,  and  the  joint  thoroughly  irrigated  with  corrosive 
solution.  Often  it  will  be  found  of  value  to  use  the  Paquelin  cautery  in  the 
walls  of  cavities  which  remain  after  the  use  of  the  chisel  and  curet.  The  opera- 
tion should  be  done  under  strict  aseptic  precautions,  and  in  a  few  cases  we 
may  expect  primary  union  to  take  place.  The  majority  of  cases,  however, 
require  drainage.     The  limb  should  be  immobilized  in  a  plaster-of-Paris  splint. 

Statistics  on  Arthrectomy. — Konig's  statistics  on  the  result  obtained 
in  150  cases  on  whom  arthrectomies  were  performed  are  as  follows:  3  died  as 
a  result  of  the  operation;  the  final  re- 
sults in  133  showed  that  94  entirely  re- 
covered of  the  local  disease,  27  showed 
that  there  was  still  evidence  of  local 
disease,  and  23  were  dead.  Of  the  94 
cases  that  entirely  recovered  from  the 
local  disease,  10  had  fair  motion;  the 
others  had  ankylosis.  Shortening  was 
absent  in  27,  slight  in  40,  moderate  in 
20,  and  marked  in  7  instances. 

2.  Resection  or  Excision. — This 
is  essentially  an  operation  to  be  per- 
formed only  in  adult  life  when  we 
wish  to  obtain  bony  ankylosis  and 
wish  to  avoid  the  long  tedious  dis- 
abihty  incident  to  conservative  treat- 
ment. It  is  practically  never  per- 
formed during  childhood,  on  account 
of  the  great  shortening  which  results 

from  removal  of  the  epiphyses.  Resection  does  not  ultimately  yield  as 
good  results  as  does  conservative  treatment,  the  mortality  rate  is  higher,  the 
functional  results  are  not  as  good,  and  in  some  cases  there  results  considerable 
flexion.  The  operation  is  performed  as  follows:  Hemorrhage  may  be  con- 
trolled by  a  tourniquet  above  the  knee ;  the  joint  is  opened  by  an  incision  similar 
to  that  described  above  for  arthrectomy.  The  joint  is  opened  and  all  diseased 
structures  are  carefully  cut  away.  Sections  of  the  femur  and  tibia  are  removed 
parallel  with  the  articular  surfaces,  until  all  the  diseased  bone  has  been  removed. 
The  joint  is  irrigated  with  salt  solution;  the  periosteum  is  stitched  together 
with  heavy  catgut.     The  wound  may  be  closed  with  or  without  drainage.     A 


Fig.  358. — Excision  of  Knee-joint. 


440  ORTHOPEDIC  SURGERY. 

sterile  dressing  is  applied  and  the  limb  placed  in  a  plaster-of-Paris  splint 
reaching  from  the  toes  to  the  upper  thigh.  While  the  bandage  is  being  applied 
care  should  be  exercised  to  avoid  any  posterior  displacement  of  the  upper  end 
of  the  femur,  and  hyperextension  should  also  be  avoided.  Windows  may  later 
be  cut  in  the  lateral  aspects  of  the  bandage  at  the  knee  to  facilitate  dressing  the 
wound.  Instead  of  plaster-of-Paris  a  posterior  splint  may  be  used.  A  good 
plan  is  to  place  the  limb  in  the  corrected  position  on  a  Cabot  posterior  wire 
splint,  and  over  this  apply  a  plaster-of-Paris  bandage.  Care  should  be  taken 
not  to  allow  the  patient  to  bear  weight  on  the  leg  for  a  number  of  months  follow- 
ing operation.  A  suitable  ambulatory  apparatus  may  be  applied  so  that  the 
patient  bears  all  the  weight  on  a  perineal  crutch. 

Statistics  on  resection.  Konig's  statistics  on  the  result  obtained  in 
300  cases  in  whom  resection  was  performed  are  as  follows:  A  good  result  was 
obtained  in  222,  there  were  6  deaths  due  to  the  operation,  and  23  occurred 
later  during  the  course  of  treatment  after  operation.  In  23  instances  it  was 
necessary  to  perform  secondary  amputations.  Of  the  222  in  which  a  good 
result  was  obtained,  their  condition  on  discharge  was:  188  cured,  31  cured  at 
some  later  date,  and  in  3  there  persisted  slight  fistulas.  In  175  cases  the  leg 
was  straighter  and  in  18  cases  there  was  deformity.  The  mortality  in  all  cases 
was  9.6  per  cent. 

Phelps'  statistics,  based  on  a  study  of  329  cases,  give  a  mortality  of  31 
cases,  or  9.4  per  cent. 

Lossen's  statistics,  based  on  an  analysis  of  586  cases  in  which  resection 
was  performed,  are:  439  entirely  healed,  59  not  healed,  50  required  secondary 
amputation,  and  38  (6.5  per  cent.)  died  as  a  result  of  the  operation  or  during 
the  course  of  the  after-treatment.  This  mortality  was  afterward  raised  to  9.4 
per  cent.,  based  on  an  observation  of  384  cases  seen  at  the  end  of  fourteen  years. 

The  mortality  rate  as  shown  by  the  above  statistics — Konig,  9.6  per  cent., 
Phelps,  9.4  per  cent.,  and  Lossen,  9.4  per  cent. — is  about  the  same. 

3.  Amputation. — Amputation  is  to  be  resorted  to  only  when  the  general 
health  of  the  patient  is  gradually  failing  and  the  disease  is  extensive  and  steadily 
progressing.  According  to  Agnew,  "excision  is  always  to  be  preferred  for 
children,  and  amputation  for  adults,"  and  this  agi'ees,  in  the  main,  with  the 
opinion  of  most  surgeons  of  large  experience,  the  question  being  largely  one 
of  individual  judgment.  In  children,  in  rare  cases,  where  the  resection  must 
remove  a  very  large  portion  of  the  shafts  of  both  bones,  amputation  may  be 
considered.     In    adults   excisions,    under    strict    antiseptic    precautions,    yield 


DISEASES  OF  THE  KNEE-JOINT.  441 

better  results  than  formerly,  and  may  be  resorted  to  when  they  offer  a  prospect 
of  cure,  amputation  being  reserved  as  a  life-saving  measure.  In  many  cases 
a  positive  decision  cannot  be  formed  until  the  joint  has  been  freely  exposed. 
The  point  of  amputation  will  depend  upon  the  judgment  of  the  operator,  but 
in  general  terms  it  can  be  stated  that  the  site  should  be  sufficiently  high  to  remove 
diseased  bone  and  tissue,  and  should  give  a  stump  that  wUl  heal  quickly  and 
be  of  service.  For  the  operation  of  amputation  readers  are  referred  to  works 
on  general  surgery. 

Mortality.  Konig's  statistics,  based  upon  690  cases  of  tuberculous 
knee-joint  disease  treated  in  the  Gottingen  clinic,  show  that  201  cases  died. 
Of  these  201  cases,  death  followed  operations  in  18  instances,  resulted  from 
causes  not  connected  with  tuberculosis  in  14  instances,  and  in  141  instances 
was  due  to  tuberculosis.  This  shows  a  mortality  rate  [of  22.5  per  cent,  of 
all  cases  treated.  The  distribution  of  the  lesions  causing  death  in  these  141 
cases  was  as  follows:  Tuberculosis  of  the  knee,  i;  acute  miliary  tuberculosis,  3; 
tuberculous  meningitis,  7;  general  tuberculosis,  30;  tuberculosis  of  the  lungs, 
94;  and  tuberculosis  in  other  parts,  6. 

These  statistics  are  much  higher  than  those  of  Gibney,  based  upon  300 
cases.  The  causes  of  death  in  the  40  cases  observed  by  Gibney  were  as  follows : 
Shock  due  to  the  operation,  i;  prolonged  suppuration,  16;  tuberculous  menin- 
gitis, 6;  tuberculosis  of  the  lungs,  3;  and  14  from  intercurrent  diseases.  Of 
these,  only  26  were  directly  due  to  tuberculosis,  so  that  a  mortality  rate  of  8.6 
per  cent.,  as  compared  with  that  given  by  Konig  (22.5  per  cent.)  shows  a 
marked  difference. 

Resume. — Tuberculous  knee-joint  disease  on  account  of  the  accessible 
nature  of  the  parts  involved  yields  very  readily  to  treatment.  The  patient's 
general  condition  should  be  carefully  investigated  and  improved  as  much  as 
possible.  Most  cases  can  be  treated  by  ambulatory  apparatus.  Conservative 
methods  yield  most  excellent  results.  The  mortality  in  children  should  not 
exceed  10  per  cent.,  and  over  50  per  cent,  of  cases  should  recover  with  good 
functional  results.  In  cases  of  suppuration  of  the  joint  with  continued  high 
fever  the  conservative  treatment  should  not  be  prolonged,  but  operative  measures 
used.  General  weakness,  presence  of  multiple  foci,  especially  advanced  phthisis 
or  severe  amyloid  degeneration,  old  age,  and  rapid  disorganization  of  the  joint 
are  indications  for  amputation. 


CHAPTER  VII. 
NON-TUBERCULOUS  KNEE-JOINT  DISEASE. 

Acute  Serous  Synovitis. 

Etiology. — Acute  serous  synovitis  of  the  knee-joint  may  be  caused  by 
direct  or  indirect  traumatism,  or  may  be  the  result  of  local  or  general  diseases. 
Following  some  local  traumatism,  there  may  occur  slight  swelling  about  the 
knee,  accompanied  by  slight  pain,  limp,  and  moderate  flexion.  Acute  synovitis 
as  a  result  of  indirect  traumatism  is  seen  in  cases  in  which  some  sudden  move- 
ment of  the  body  gives  a  sharp  twist  at  the  knee-joint;  it  may  also  follow  turning 
over  suddenly  in  bed,  so  that  forcible  rotation  is  made  at  the  knee;  may  follow 
"catching  the  toes"  over  some  unseen  obstacle,  as  the  edge  of  the  carpet,  curb- 
stone, etc.  It  is  seen  very  commonly  in  football  players  and  men  engaged  in 
track  athletics,  baseball,  hockey,  etc.  It  may  be  a  local  manifestation  of  some 
general  disease,  as  rheumatism,  scarlet  fever,  smallpox,  t}^hoid  fever;  or  may 
be  due  to  a  local  inflammatory  condition  near  the  joint,  as  a  septic  prepatellar 
bursitis,  septic  abrasions,  and  furuncles  near  the  knee-joint.  Occasionally  it 
is  found  as  a  symptom  of  urethral  fever. 

Pathology. — The  effusion  following  mild  traumatism  varies  in  amount, 
is  yellowish,  clear,  contains  albumen  and  a  few  red  and  white  blood-corpuscles. 
If  the  injury  has  been  severe,  there  is  usually  moderate  hemorrhage,  so  that  the 
fluid  is  yeUowish-red ;  there  is  also  a  certain  amount  of  fibrin,  which  in  time  is 
deposited  on  the  entire  synovial  membrane.  The  synovial  membrane  is  usually 
edematous  and  throughout  presents  small  areas  of  ecchymosis.  If  the  effusion 
is  rapidly  absorbed,  the  joint  usually  returns  to  its  normal  appearance;  but  if 
the  condition  becomes  chronic,  the  fibrin  becomes  organized,  all  intra-articular 
and  peri-articular  structures  gradually  becomes  thickened  and  softened,  but  if 
resolution  occurs  all  the  tissues  return  to  their  normal  condition  without  injury. 

Symptoms. — The  most  characteristic  symptom  of  acute  synovitis  is  the 
sii'elHng  which  takes  place  as  a  result  of  the  increased  amount  of  fluid  in  the 
knee-joint.  The  para-patellar  grooves  are  obliterated  and  in  their  place  are 
found  distinct  bulgings  which  may  in  extreme  cases  extend  upward  and  merge 
above  the  patella.     Usually  the  swelling  is  continued  upward  above  the  patella 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  443 

for  a  distance  of  three  to  four  inches,  corresponding  with  the  subcrureous  bursa; 
and  at  times  a  swelling  may  be  found  in  the  popliteal  space  due  to  the  connection, 
which  occasionally  occurs,  of  the  bursse  of  the  semi-membranosus  and  popliteal 
bursae.  Fluchiation  is  of  varying  degrees,  and  is  found  best  by  having  the  leg 
in  full  extension  and  by  the  examiner  standing  on  the  outside  of  the  knee,  oblit- 
erating the  subcrureous  bursas  with  the  palm  of  the  right  hand  when  examining 
the  left  knee,  and  vice  versa,  the  thumb  of  the  right  hand  being  placed  along 
the  outside  of  the  patella,  and  excess  of  fluid  can  be  noticed  by  gently  tapping 
on  the  inner  side  of  the  knee  close  to  the  patella  by  the  fluid  wave  which  is 
conveyed  to  the  thumb  of  the  right  hand.  The  amount  of  effusion  can  be 
determined  by  the  extent  to  which  the  patella  is  floated.  The  leg  should  be  in 
full  extension,  otherwise  small  amounts  of  effusion  will  be  overlooked.  There 
may  be  slight  increase  of  local  temperature.  The  knee  is  slightly  flexed.  Pain 
is  practically  absent,  except  in  extreme  flexion. 

Diagnosis. — This  rests  upon  the  acute  local  signs,  history  of  injury,  and 
absence  of  subjective  symptoms.  It  is  to  be  distinguished  from  tuberculous 
ostitis  and  hysteric  joint. 

Treatment. — The  entire  limb  should  be  immobilized  in  a  plaster-of-Paris 
splint,  celluloid  splint,  posterior  tin  or  wood  splint  for  several  days  until  the 
swelling  has  disappeared.  Locally  flying  blisters  and  tincture  of  lodin  do  good 
in  the  beginning.  This  immobilization  may  be  combined  with  pressure  by 
means  of  adhesive  plaster,  rubber  elastic  bandages,  compressed  sponges,  or 
repeated  graduated  pressure.  After  the  acute  symptoms  have  subsided  massage 
and  hot  air  are  of  much  benefit  in  promoting  the  absorption  of  the  effusion. 
During  the  active  stage  and  until  convalescence  is  well  established  the  patient 
should  use  crutches,  and  should  afterward  avoid  sudden  jars  or  twists  which 
might  reproduce  the  same  condition  in  a  joint  favorably  disposed. 

Chronic  Serous  Synovitis. 

Etiology. — Chronic  serous  synovitis  is  usually  preceded  by  acute  serous 
synovitis.  In  many  cases  of  acute  synovitis  the  acute  symptoms  graduafly 
subside,  leaving  a  knee-joint  which  usually  contains  a  slight  amount  of  fluid 
and  causes  considerable  disability;  very  often  the  acute  form  may  be  due  to 
some  internal  derangement  following  injury,  and  on  the  least  provocation  all 
symptoms,  but  to  a  less  degree,  occur  that  w^ere  present  in  the  acute  attack. 
Among  the  causes  to  be  ascribed  to  this  condition  may  be  mentioned  fringes, 
loose  bodies,  lax  ligaments,  partial  dislocations  of  the  patella,  and  loose  semi- 


444  ORTHOPEDIC  SURGERY. 

lunar  cartilages.  The  condition  may  occasionally  be  chronic  from  the  beginning, 
in  which  case  it  is  usually  due  to  some  general  disease  or  malnutrition. 

Pathology. — If  the  condition  present  in  acute  serous  synovitis  continues, 
organization  of  fibrin  takes  place  within  the  joint,  the  synovial  membrane  re- 
mains thickened,  considerable  peri-articular  edema  takes  place,  exfoliation  of 
the  cartilage  occurs,  exuberant  granulation  tissue  forms  from  the  edges  of  the 
cartilages  project  into  the  joint  cavity  as  s3Tiovial  fringes,  become  free,  forming 
loose  bodies,  and  finally  there  occurs  a  relaxed  condition  of  the  articular  struc- 
tures with  lateral  mobility,  so  that  the  muscles  finally  fail  to  control  the  joint. 

Symptoms. — The  subjective  symptoms  are  those  that  can  be  attributed  to 
the  relaxed  condition  of  the  joint.  The  history  is  usually  one  of  repeated  attacks 
of  acute  serous  s)rnovitis  resulting  from  traumatism.  Pain  when  present  is 
usually  diffused  about  the  joint,  there  may  be  some  hyperesthesia  of  the  skin. 
The  patient  complains  of  a  feeling  of  weakness  in  the  joints,  inability  to  lift 
heavy  weights,  and  at  times  is  unable  to  support  the  weight  of  the  body  on  the 
joint  for  any  considerable  period.  Objectively  swelling  occurs  early,  oblitera- 
ting the  parapatellar  grooves,  and  causes  floating  up  of  the  patella.  The  mo- 
bility of  the  joint  is  not  interfered  with  except  in  cases  due  to  loose  cartilages  and 
bodies  in  the  joint;  in  fact,  in  most  cases  lateral  motion  is  possible  to  a  greater 
or  less  extent.  In  some  cases  distinct  crepitation  can  be  felt,  which  may  varj' 
from  a  leathery  crepitation  to  one  of  a  rough,  grating  character.  This  is  due 
to  plastic  deposits  on  the  synovial  membrane,  fringes  catching  between  the 
articular  surface,  and  para-articular  areas  of  induration. 

Diagnosis. — Chronic  serous  synovitis  is  diagnosed  by  the  history,  the 
duration  of  the  disease,  the  presence  of  fluctuations,  floating  up  of  the  patella, 
absence  of  muscular  spasm,  limitation  of  motion,  fever,  and  signs  of  local  inflam- 
mation, involvement  being  confined  to  the  synovial  membrane,  lax  condition 
of  the  periarticular  structures,  and  occasionally  by  the  presence  of  distinct  crepi- 
tation within  the  joint. 

It  is  to  be  distinguished  from  tuberculous  joint  disease  by  the  history,  absence 
of  periarticular  induration,  fever,  muscular  spasm,  and  flexion.  From  pre- 
patellar bursitis  it  is  distinguished  by  the  history,  by  the  swelling  being  confined 
to  the  prepatellar  region,  and  absence  of  fluid  in  the  joint  and  floating  up  of  the 
patella  in  the  latter  condition. 

Treatment. — Chronic  serous  synovitis  does  not  yield  readily  to  treatment. 
This  consists  of  moderate  fixation,  protection,  compression,  and  in  the  later 
stages  of  massage,  hot  air,  and  supports. 


N  ON -TUBERCULOUS  KNEE-JOINT  DISEASE.  445 

Fixation  may  be  by  means  of  plaster-of-Paris  or  a  posterior  tin  or  wood 
splint.  This  should  be  continued  until  the  more  active  symptoms  have  somewhat 
subsided,  when  moderate  motion  should  be  allowed  if  the  joint  is  well  protected. 
Compression  can  be  obtained  by  adhesive  plaster  applied  diagonally  around  the 
knee,  from  six  to  eight  inches  below  to  the  same  distance  above,  and  a  space 
should  be  allowed  posteriorUy  so  as  not  to  retard  the  circulation.  Dry  sponges 
may  be  applied  around  the  knee  by  means  of  a  bandage,  and  when  wet  will 
expand  causing  compression.  The  entire  leg  and  thigh  may  be  surrounded  by 
sheet  wadding,  and  outside  this  a  layer  of  binder's  board  which  has  been  made 
pliable  by  hot  water,  and  around  the  entire  dressing  a  firm  bandage  applied. 
Instead  of  the  binder's  board  a  bandage  may  be  applied  around  the  sheet 
wadding  and  reinforced  daUy.  Elastic  bandages  and  elastic  knee  stockings  may 
be  used  to  cause  compression. 

During  the  entire  course  of  chronic  serous  synovitis  the  use  of  massage  and 
hot  air  has  been  attended  by  very  beneficial  results.  It  promotes  the  circula- 
tion about  the  joint,  thereby  increasing  the  absorption  of  the  efl'usion,  and  at 
the  same  time  it  helps  to  tone  up  the  lax  condition  of  the  muscles  and  ligaments. 

The  advisability  of  incision  and  irrigation  in  obstinate  cases  of  chronic 
synovitis  is  at  present  debatable.  While  some  incline  to  this  radical  procedure, 
others  hold  to  the  more  conservative  measures.  The  fluid  in  the  joint  may  be 
removed  by  aspiration  and  the  entire  synovial  sac  filled  with  carbolic  acid  solu- 
tion (3  per  cent.)  which  is  removed  and  renewed  until  the  fluid  returns  clear. 
All  fluid  is  then  expressed  and  a  compression  bandage  and  posterior  splint  or 
plaster-of-Paris  splint  applied  for  a  week  or  ten  days.  If  at  the  end  of  this  time 
the  fluid  is  not  entirely  absorbed,  the  procedure  may  be  repeated  several  times. 
Tincture  of  iodin  and  a  10  per  cent,  iodoform-ofl  emulsion  are  other  solutions  that 
have  been  employed  instead  of  the  carbolic  acid  solution.  Some  operators 
prefer  to  incise  the  joint,  irrigate  thoroughly  with  carbolic  acid  solution  (3  per 
cent.)  or  corrosive  sublimate  solution  (i  :  5000),  normal  salt  solution  or  sterile 
water,  and  after  expressing  the  excess  of  fluid  to  close  the  wound  and  apply  a 
compression  and  fixation  dressing.  Opening  of  the  knee-joint  has  always  been 
attended  with  considerable  risk  to  the  patient,  and  the  author  does  not  feel 
warranted  from  a  study  of  the  cases  seen  and  reported  to  advise  this  radical 
procedure,  as  long  as  the  contents  of  the  joint  remain  serous.  Patients  who  are 
subject  to  this  condition  should  always  wear  an  elastic  bandage,  stocking,  or 
some  support  to  protect  the  knee-joint  from  sudden  twists  and  jars. 


446  ORTHOPEDIC  SURGERY. 

Acute  Suppurative  Arthritis— Phlegmon. 

Etiology. — Acute  suppurative  arthritis  of  the  knee  may  occur  after  incised 
and  gunshot  wounds  entering  the  joint,  localized  infections  near  the  joint,  may 
be  due  to  the  infectious  diseases,  may  follow  operations  upon  the  joint,  and  in 
children  may  be  primary  within  the  joint  or  secondary  to  an  acute  epiphysitis. 

Pathology. — As  a  result  of  infection  the  synovial  membrane  becomes  hy- 
peremic,  stasis  of  the  blood-current  occurs,  the  capillaries  dilate,  followed  by  an 
outwandering  of  leukocytes  and  hypersecretion  of  synovial  fluid.  The  infiltrated 
walls  of  the  synovial  membrane  become  red,  edematous,  and  lusterless;  the  peri- 
articular structures  gradually  become  infiltrated,  swollen,  and  adherent  to 
surrounding  structures.  The  contour  of  the  joint  rapidly  changes,  the  synovial 
sac  becomes  very  tense,  its  layers  become  disorganized  and  necrotic,  and  finally 
ruptures  into  the  surrounding  structures,  with  the  formation  of  abscesses  running 
up  the  thigh  and  down  the  leg,  guided  by  the  intramuscular  septa,  fistulas  and 
entire  destruction  of  the  joint.  The  severity  of  the  infection  depends  upon 
the  cause,  and  the  results  obtained  depend  upon  the  promptness  of  operative 
interference. 

Symptoms . — As  a  result  of  one  of  the  causes  cited  above,  there  may  occur 
slight  swelling  of  the  knee-joint,  accompanied  by  increased  synoAaal  fluid, 
absence  of  fever  for  a  few  days,  very  little  pain,  some  local  tenderness,  gradually 
however,  the  temperature  begins  to  rise  rapidly,  giving  the  first  suspicion  of 
suppuration  taking  place  within  the  joint.  The  fever  continues  high,  ranging 
between  103°  and  105°,  accompanied  by  rapid  pulse-rate,  sweats,  and  chills; 
pain  becomes  marked,  especially  on  motion,  flexion  occurs;  instead  of  the 
normal  color  and  appearance  of  the  skin,  the  latter  becomes  tense,  red, 
edematous  and  glossy;  the  local  temperature  is  increased;  the  leg  and  foot 
become  enlarged,  tender,  and  pits  on  pressure,  due  to  obstruction  of  the 
venous  return  from  pressure;  lymphangitis  occurs,  the  femoral  glands  become 
enlarged,  tender,  and  may  fluctuate;  fluctuations  and  floating  up  of  the 
patella  occur.  The  constitutional  signs  are  very  marked ;  there  are  distressing 
headache,  loss  of  appetite,  vomiting,  and  in  severe  cases  delirium  and  coma. 

Treatment. — In  no  joint  disease  are  operative  measures  more  urgently 
called  for  than  in  acute  suppurative  knee-joint  disease.  If  the  condition  is 
suspected,  the  joint  should  be  aspirated  under  most  aseptic  precautions.  If 
the  fluid  obtained  is  turbid,  flocculent,  or  purulent,  and  microscopic  examination 
of  the  fluid  shows  the  presence  of  micro-organisms,  the  joint  should  be  thoroughly 
incised,  irrigated  and  drained.     The  joint  may  be  opened  by  t^'o  long  curved 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  447 

incisions  on  either  side  of  the  patella,  the  joint  cavity  thoroughly  exposed, 
irrigated  with  salt  solution,  drained  freely,  a  moist  antiseptic  dressing  applied, 
and  the  limb  placed  on  a  posterior  wire  splint.  The  knee-joint  may  also  be 
widely  opened  by  a  transverse  incision  carried  above,  below,  or  through  the 
patella.  At  times  it  may  be  found  necessary  to  have  dependent  drainage  through 
the  popliteal  space.  Whatever  incisions  may  be  used,  drainage  should  be 
thorough  and  free.  In  many  cases  abscesses  will  form  along  the  intermuscular 
septa  below  and  above  the  knee,  which  will  require  multiple  incisions  and 
drainage.  In  gunshot  injuries  and  when  the  articular  surfaces  are  destroyed, 
resection  may  be  necessary.  In  most  cases  complete  ankylosis  occurs.  If 
the  infection  is  very  severe,  as  shown  by  the  local  condition  and  evidence  of 
septic  absorption,  amputation  may  be  necessary  to  save  life  and  should  never 
be  delayed. 

The  deformity  following  acute  suppurative  arthritis  is  usually  moderate 
flexion  combined  with  outward  rotation  and  abduction  of  the  leg.  Throughout 
the  treatment  efforts  should  be  made  to  prevent'  this  deformity  by  means  of 
suitable  splints. 

The  after-treatment  consists  in  massage,  hot  air,  electricity,  active  and 
passive  exercises.  If  deformity  is  present,  attempts  should  be  made  to  correct 
it  according  to  the  degree  of  ankylosis  present,  as  described  in  the  chapter 
on  ankylosis. 

Prepatellar  Bursitis. 

Of  the  bursas  not  communicating  with  the  knee-joint,  the  one  most  frequently 
the  seat  of  disease  is  the  prepatellar  bursa.  This  is  accounted  for  by  its  exposed 
position  and  by  the  fact  that  in  kneeling  considerable  weight  is  thrown  upon 
the  lower  edge  of  the  patella  and  patellar  ligament.  The  prepatellar  bursa 
lies  between  the  skin  and  the  patella  and  upper  half  of  the  patellar  ligament. 
It  is  not  always  well  defined,  and  usually  consists  of  three  portions, — the 
subcutaneous,  subaponeurotic,  and  subtendinous, — all  usually  communicating 
with  each  other. 

These  bursEe  may  be  subject  to  acute,  chronic,  and  suppurative  inflam- 
mation. 

Acute  Prepatellar  Bursitis. — This  usually  follows  as  a  direct  result 
of  traumatism,  but  may  be  due  to  a  localized  inflammatory  condition  of  the 
skin  near  the  bursse,  or  to  overuse. 

Symptoms  and  Diagnosis.    Following  trauma  or  a  localized  sepsis  of 


448  ORTHOPEDIC  SURGERY. 

the  skin  there  occur  swelling  and  fluctuation  confined  to  the  prepatellar  region, 
which  is  made  more  tense  by  flexion,  some  pain  on  flexion,  and  tenderness 
on  pressure.  It  is  dtEferentiated  from  synovitis  by  the  localization  of  the  swell- 
ing to  the  prepatellar  region,  by  absence  of  fluid  in  the  joint,  and  floating  up  of 
the  patella. 

Treatment.  This  consists  in  placing  the  joint  at  rest  by  the  application 
of  a  posterior  splint  and  use  of  crutches.  In  addition,  counterirritants  may 
be  used,  as  tincture  of  iodin,  cantharides,  etc.  The  fluid  may  be  removed 
by  aspiration  and  compression  applied.  In  the  acute  cases  compression  by 
means  of  elastic  bandages,  wet  sponges,  etc.,  is  very  beneficial.  If  the  condition 
is  due  to  a  localized  area  of  inflammation,  appropriate  treatment  for  the  latter 
will  soon  be  followed  by  favorable  results.  • 

Chronic  Prepatellar  Bursitis. — This  condition  may,  though  it  rarely 
does,  follow  an  acute  attack.  It  is  usually  seen  among  those  who  are  com- 
pelled in  their  work  to  spend  considerable  time  on  their  knees.  This  is 
especially  so  among  those  whose  work  requires  leaning  fora-ard  laterally 
and  backward  on  their  knees,  as  "in  the  occupation  of  scrubbing  floors.  These 
motions,  especially  that  of  leaning  forward,  bring  considerable  pressure 
over  the  prepatellar  region,  which  in  time  produces  marked  thickening  of 
the  walls  of  the  bursae  and  the  exudation  of  fluid  into  the  burss.  This  gradu- 
ally leads  to  the  formation  of  a  tumor  varying  in  size,  and  at  first  limited  to  the 
prepatellar  region.  As  the  condition  becomes  chronic,  there  are  formed  within 
the  bursas  thick  fibrous  bands  which  usually  run  from  the  walls  of  the  bursae 
and  may  project  free  into  the  cavity  or  be  attached  to  the  opposite  wall. 

Synonym.     "Housemaid's  knee." 

Symptoms.  Excepting  some  limitation  of  flexion,  the  subjective 
symptoms  are  very  slight.  The  patient  is  unable  to  state  definitely  when  the 
sweUing  was  first  noticed.  This  is  fairly  firm,  semi-fluctuating,  of  rather  doughy 
consistency,  limited  to  the  prepatellar  region,  made  tense  on  flexion,  and  the 
overlying  skin  is  of  a  brawny  character. 

Diagnosis.  It  is  dift"erentiated  from  synovitis  by  the  occupation  of  the 
patient,  by  its  limitation  to  the  prepatellar  region,  by  its  tenseness  on  flexion 
of  the  knee,  by  the  absence  of  fluctuation  in  the  knee,  and  by  the  fact  that  the 
patella  does  not  float. 

Treatment.  In  the  mild  form  of  chronic  bursitis  the  fluid  may  be  aspirated 
and  the  bursae  filled  with  a  3  to  5  per  cent,  carbolic  acid  solution,  washing  the 
latter  out  with  sterUe  water  and  then  applying  a  posterior  splint  and  compression. 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  449 

If  this  fails,  and  in  the  author's  experience  it  usually  does,  the  bursas  may  be 
dissected  out  through  a  transverse,  vertical,  or  curved  incision,  using  throughout 
the  most  thorough  aseptic  precautions.  The  wound  may  be  closed,  a  sterUe 
dressing  and  posterior  splint  applied,  with  the  expectation  of  allowing  the 
patient  to  resume  work  in  four  to  five  weeks;  or  the  bursse  may  be  opened, 
the  walls  cureted  and  allowed  to  heal  by  granulation.  In  the  very  severe 
forms  the  only  possible  means  by  which  a  cure  can  be  obtained  is  by  thorough 
dissection  of  the  sac  from  the  surrounding  structures. 

Suppurative  Prepatellar  Bursitis. — This  condition  may  be  the  result 
of  an  acute  or  a  chronic  bursitis,  especially  the  acute  form  due  to  a  localized 
septic  process  as  a  furuncle  or  a  lacerated  septic  wound. 

Symptoms.  Suppuration  of  the  bursa  is  shown  by  heat  and  redness 
of  the  skin,  by  swelling,  at  first  limited  to  the  prepatellar  region,  but  later  it 
may  extend  in  all  directions  and  simulate  a  suppurative  arthritis.  There 
is  usually  a  septic  wound  near  to  or  entering  into  the  bursse.  Fever,  moder- 
ate pain  or  flexion,  lymphangitis,  enlargement  of  the  femoral  lymphatic  glands, 
are  usually  present  in  this  condition. 

It  is  differentiated  from  suppurative  arthritis  by  the  absence  of  fluid  in 
the  joint,  by  the  fact  that  the  patella  does  not  float  upward,  and  by  the  limi- 
tation to  the  prepatellar  region. 

Treatment.  This  consists  in  free  incision,  cureting  thoroughly,  or  at 
times  excising  the  sac,  and  allowing  the  wound  to  close  by  granulation. 

Pretibial  Bursitis. 

The  pretibial  bursae  are  two  in  number — the  superficial  and  the  deep. 
The  superficial  pretibial  bursa  is  situated  between  the  skin  and  the  tibial  tu- 
bercle, at  the  insertion  of  the  patellar  ligament. 

The  deep  pretibial  bursa  lies  between  the  patellar  tendon  and  the  peri- 
osteum of  the  tibia.  It  is  triangular  in  shape,  and  extends  from  the  tibial  tuber- 
cle upward  as  far  as  the  joint.  The  superficial  bursa  may  communicate  with 
the  prepatellar  bursa,  but  the  latter  never  communicates  with  this  bursa  or 
with  the  knee-joint.     Inflammation  of  these  bursce  are  usually  due  to  injury. 

Symptoms. — Inflammation  of  the  superficial  pretibial  bursa  is  recog- 
nized by  the  appearance  of  a  swelling  over  the  tibial  tubercle,  and  may  simu- 
late hypertrophy  of  the  tubercle;  there  is  usually  locahzed  pain  and  tender- 
ness on  pressure.  Tension  in  the  bursa  is  not  influenced  by  movements  at 
the  knee-joint. 


450  ORTHOPEDIC  SURGERY. 

Inflammation  of  the  deep  pretibial  bursa  is  recognized  by  the  appear- 
ance on  either  side  of  the  patellar  ligament  of  a  fluctuating  swelling  obliterat- 
ing the  normal  parapatellar  grooves.  There  is  usually  considerable  inter- 
ference with  motion,  which  is  accompanied  by  pain.  The  condition  resem- 
bles an  effusion  in  the  knee-joint  on  account  of  the  position  of  the  swelling, 
but  while  fluctuation  is  present  there  is  never  any  floating  up  of  the  patella. 
This  bursa  may  be  the  subject  of  acute,  chronic,  or  suppurative  inflammation. 

Treatment. — The  eft'usion  in  the  superficial  form  will  usually  disap- 
pear by  strapping  with  adhesive  plaster  or  some  form  of  compression.  In 
the  deep  variety  the  effusion  wiU  usually  disappear  -ndth  immobilization,  com- 
pression, moist  heat  in  the  form  of  compresses  or  by  hot  air.  If  this  is  in- 
eft'ective,  the  sac  may  be  aspirated  and  washed  out  with  carbolic  acid  (3  to 
4  per  cent,  solution)  and  then  immobilization  and  compression  applied. 
This  will  in  most  cases  be  followed  by  favorable  results.  In  the  suppura- 
tive variety  the  bursa  should  be  incised,  drained,  and  allowed  to  heal  by 
granulation.  If  operative  interference  is  sufficiently  prompt,  infection  of  the 
knee-joint  may  be  avoided. 

Enlargement  and  Fracture  of  the  Tibial  Tubercle. 

Enlargement  of  the  tibial  tubercle  is  usually  due  to  a  localized  osteitis 
or  periosteitis  following  injury  or  bursitis  of  the  superficial  pretibial  bursa. 
It  consists  of  thickening  of  the  tubercle,  which  is  slightly  tender  on  pressure, 
and  is  shown  externally  by  moderate  swelling.  At  times  there  may  be  indis- 
tinct fluctuation  or  elasticity  over  a  hard  base.  The  condition  usually  im- 
proves with  the  local  application  of  tincture  of  iodia  or  some  other  counter- 
irritant. 

Separation  of  the  tibial  tubercle  is  usually  due  to  muscular  action.  It 
rarely  occurs  from  direct  violence,  and  is  more  common  during  adolescence. 
Examination  shows  the  presence  of  a  small  irregular  bony  mass  about  the  size 
of  a  walnut,  which  is  drawn  upward  with  the  patellar  ligament  by  the  action 
of  the  quadriceps  extensor  muscles;  this  is  accompanied  by  tenderness  on 
pressure,  by  eft'usion  into  the  knee-joint,  and  by  inability  to  extend  the  leg 
fully.  Treatment  consists  in  immobilization  on  a  posterior  splint  and  trac- 
tion by  means  of  adhesive  plaster  placed  above  the  separated  tubercle.  This 
will  usually  bring  the  tubercle  nearly  to  its  normal  position  and  will  give  a  use- 
ful joint.  If  it  is  impossible  to  draw  the  tubercle  down  to  its  normal  position, 
it  mav  be  cut  down  upon  under  the  most  careful  aseptic  precautions  and  the 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  451 

torn  periosteum  sutured.  The  wound  should  be  closed,  covered  by  a  sterile 
dressing,  and  a  plaster-of-Paris  bandage  applied  from  the  toes  to  the  upper 
thigh.  At  the  end  of  one  month  the  patient  may  be  allowed  on  crutches,  and 
to  use  the  leg  at  the  end  of  two  months. 

Popliteal  Bursas  and  Cysts. 

Cysts  found  in  the  popliteal  space  usually  have  their  origin  in  bursae 
formed  by  protrusions  of  the  synovial  membrane  of  the  knee-joint.  These 
cysts  may  continue  to  be  connected  with  the  joint  or  after  a  time  there  may 
be  nothing  to  suggest  their  connection  with  the  joint.  The  view  has  been 
expressed  by  Riese  ("  Centralblatt  fiir  Chirurgie,"  1898,  p.  585)  that  these 
swellings  have  no  connection  with  the  joint,  but  are  true  cystic  tumors  of 
degenerated  fibrous  tissue.  He  found  that  in  the  blood-vessels  supplying 
these  tumors  there  existed  an  obliterating  endarteritis. 

These  cysts  are  found  in  early  adult  life.  They  vary  in  size  from  a 
small  walnut  to  irregularly  shaped  tumors  that  may  extend  from  the  mid- 
thigh  to  the  mid-leg.  As  a  rule,  they  attain  the  size  of  a  pigeon's  egg.  They 
may  be  situated  along  the  inside  of  the  semi-membranosus  tendon,  they  may 
form  between  the  origin  of  the  two  heads  of  the  gastrocnemius  muscle,  or 
may  lie  just  inside  the  tendon  of  the  biceps. 

Symptoms. — They  are  usually  recognized  on  extension  of  the  leg,  and 
cause  a  feeling  of  tension,  or  at  times  extreme  pain  on  walking.  At  times 
they  become  so  large  as  to  cause  pressure  on  the  veins  in  the  popliteal  space. 
If  they  communicate  with  the  knee-joint,  pressure  upon  them  will  decrease 
their  size  and  cause  an  increased  amount  of  fluid  in  the  knee-joints. 

Diagnosis. — They  are  to  be  differentiated  from  lipoma,  sarcoma,  tuber- 
cular abscesses,  and  aneurysm.  The  diagnosis  rests  upon  the  presence  of 
a  painless,  smooth,  fluctuating  swelling  in  the  popliteal  space  which  may  be 
decreased  by  pressure,  and  this  is  accompanied  by  effusion  into  the  knee- 
joint  and  through  the  two  sacs  distinct  fluctuation  can  be  felt. 

Treatment. — On  account  of  the  proximity  of  the  popliteal  vessels  com- 
pression cannot  be  used.  In  those  which  do  not  communicate  with  the  joint, 
the  fluid  may  be  aspirated  and  the  sac  irrigated  with  carbolic  acid  (3  per  cent.) 
or  tincture  of  iodin.  If,  however,  they  communicate  with  the  joint,  the  only 
treatment  that  will  be  followed  by  favorable  results  is  thorough  dissection 
of  the  sac  from  surrounding  structures  under  aseptic  precautions. 


452  ORTHOPEDIC  SURGERY. 

Loose  Bodies  in  the  Knee-joint — Joint  Mice. 

Loose  bodies  in  the  joints  other  than  the  knee  are  rarely  seen.  This  is 
probably  due  to  the  fact  that  the  anatomy  and  position  of  this  joint  render  it 
particularly  liable  to  injury.  About  90  per  cent,  of  loose  bodies  are  found 
in  the  knee-joint. 

Etiology. — At  one  time  it  was  thought  that  free  bodies  resulted  from 
injury  to  the  knee-joint.  In  many  cases  this  was  so  slight,  and  in  some  no 
history  of  injury  could  be  obtained,  so  that  it  is  doubtful  if  trauma  alone  can 
be  the  etiologic  factor.  Claims  have  been  made  that  by  twists  or  by  direct 
injury  portions  of  the  articular  cartilage  were  torn  off;  experiments,  however, 
have  been  made  to  show  that  great  violence  is  necessary  to  separate  frag- 
ments from  the  articular  surface.  Konig,  among  others,  holds  to  the  view 
that  they  are  formed  by  a  process  of  osteochondritis  following  trauma,  and 
that  they  are  gradually  separated  from  the  bone  in  this  way.  Bradford  holds 
that,  following  injury,  these  pieces  are  so  injured  and  bruised  that  necrosis 
takes  place,  and  as  a  result  an  osteochondritis  which  finally  leads  to  their 
separation.  Barth  considers  that  those  cases  in  which  the  lesion  is  situated 
on  the  internal  condyle  near  the  intercondyloid  fossa  follow  tearing  of  the 
crucial  ligaments  caused  by  sudden  rotation  of  the  leg.  As  a  pathologic  con- 
dition free  bodies  are  seen  in  arthritis  deformans. 

Constituents  of  Loose  Bodies. — The  free  bodies  found  in  arthritis  de- 
formans consist  of  detached  portions  of  bone  and  cartilage  and  villi  consist- 
ing of  cartilage  and  bone  which  have  been  detached  from  the  synovial  mem- 
brane and  are  known  as  synovial  fringes.  Those  found  in  otherwise  normal 
joints  consist  of  cartilage;  cartilage  and  bone,  either  of  which  may  form  as 
a  nucleus  and  be  surrounded  by  the  other;  fibrin  surrounded  by  cartUage, 
the  fibrin  being  the  remains  of  an  old  effusion,  and  encapsulated  foreign 
bodies. 

These  loose  bodies  vary  in  size,  number,  and  shape.  They  may  be  in 
size  anywhere  from  that  of  a  mUlet-seed  to  that  of  a  walnut.  In  number 
they  have  been  found  singly,  three  to  four  at  a  time,  and  one  case  is  reported 
in  which  about  four  hundred  were  removed  from  the  knee-joint.  In  shape 
they  have  been  found  to  vary.  When  a  number  are  present,  they  may  be 
shaped  like  melon-seeds  or  may  be  pyriform.  Or  if  only  a  few  are  present, 
they  are  usually  faceted  and  may  be  concavo-convex.  These  bodies  may 
be  free  or  be  attached  by  a  pedicle. 

Symptoms. — In  most  cases  the  first  symptom  that  the   patient  notices 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  453 

is  while  engaging  in  some  rather  violent  exercise  in  which  the  knee  is  given 
a  sudden  twist,  or  simply  while  walking  or  stooping,  there  is  sudden  agoniz- 
ing pain  in  the  joint,  which  in  some  instances  is  so  great  as  to  render  the  pa- 
tient sick  and  faint;  he  is  unable  to  straighten  his  knee,  and  falls  to  the  ground 
in  great  pain.  This  is  followed  by  an  acute  synovitis  which  gradually  sub- 
sides, leaving  a  joint  in  which  there  is  moderate  effusion  and  which  the  patient 
feels  is  somewhat  weakened.  Before  this  acute  attack,  however,  there  may 
have  been  some  slight  trauma  which  the  patient  failed  to  notice,  but  which 
he  will  remark  if  his  attention  is  called  to  it,  that  there  was  for  an  indefinite 
time  preceding  the  acute  attack,  slight  grating  on  extension  and  an  occasional 
swelling  of  the  joint,  which,  however,  did  not  in  any  way  interfere  with  its 
function.  There  may  be  a  repetition  of  these  acute  attacks,  occurring  at  ir- 
regular periods;  at  times  the  patient  suddenly  twists  the  knee  while  it  is 
slightly  flexed,  or  while  walking  is  unable  to  extend  the  knee,  or  sometimes 
the  reverse;  there  is  the  feeling  as  though  something  is  caught.  After  a  time 
the  motions  of  the  joint  are  unrestricted,  but  there  follows  an  effusion  into 
the  joint.  These  attacks  may  occur  so  frequently  as  to  render  the  joint  entirely 
untrustworthy,  and  the  joint  cavity  continually  distended  with  fluid,  but 
with  the  lessening  of  the  intervals  between  the  attacks  the  joint  reacts  less 
to  injury  and  the  synovitis  is  not  so  severe. 

Very  often  these  loose  bodies  may  be  felt  through  the  soft  parts  about 
the  joint.  They  are  usually  detected  over  the  condyles  of  the  femur  to  either 
side  of  the  patella,  or  at  times  may  be  felt  over  the  tibia  near  the  patellar  liga- 
ment. At  times  it  is  impossible  to  find  them,  and  when  found  they  readily 
escape. 

Diagnosis. — This  rests  upon  the  history  and  the  detection  of  the  loose 
body.  At  times  we  must  depend  upon  the  statement  of  the  patient  that  he 
can  feel  the  body,  and  after  repeated  examination  we  may  be  fortunate  enough 
to  be  able  to  detect  it.  To  differentiate  the  presence  of  loose  bodies  from 
dislocation  of  the  semilunar  cartilage  is  at  times  very  difficult.  In  the  latter 
condition  the  catch  in  the  joint  is  always  from  flexion  to  extension,  and  in  the 
former  the  reverse  is  often  the  case;  in  the  latter  there  is  usually  a  very  tender 
point  over  the  inner  head  of  the  tibia,  and  to  produce  extension  from  a  flexed 
position,  pressure  at  this  point,  with  outward  rotation  of  the  leg,  is  usually 
necessary. 

Treatment. — If  the  loose  bodies  are  the  result  of  arthritis  deformans, 
it  is  often  not  advisable  to  remove  them,  as  the  joint  may  be  so  far  destroyed 


454  ORTHOPEDIC  SURGERY. 

that  little  good  would  result.  In  the  other  class  of  cases  the  only  method  of 
treatment  that  wiU  be  of  use  is  operative  interference.  Most  thorough  asepsis 
should  be  employed.  If  possible  to  detect  the  body,  it  may  be  held  in  place 
by  a  needle  transfixing  it,  and  then  the  needle  used  as  a  guide.  If  this  is  not 
feasible,  the  joint  should  be  opened  and  thorough  search  made  and  all  bodies 
removed.  Irrigation  of  the  joint  is  not  advisable.  The  wound  should  be 
closed  without  drainage  by  layer  sutures,  and  a  sterile  dressing  and  posterior 
splint  then  applied. 

Dislocation  of  the  Semilunar  Cartilages. 

Synonym. — Hey's  internal  derangement. 

Etiology. — The  majority  of  cases  are  due  to  traumatism  indirectly  applied. 
The  resulting  lesion  is  a  forcible  tearing  of  one  or  rarely  both  semilunar  cartilages, 
from  the  anterior  or  posterior  aspect  of  the  spine  of  the  tibia  or  from  along 
its  peripheral  attachment  to  the  capsule  or  cartilaginous  surface  of  the  tibia. 
In  some  cases  the  cartilage  may  be  torn  in  one  or  several  places  in  a  radiating 
direction.  It  may  be  entirely  detached  and  forced  into  the  joint  or  may  not 
be  displaced  at  aU.  The  internal  semilunar  cartUage  is  most  frequently  affected. 
This  is  accounted  for  by  the  fact  that  the  motion  which  is  necessary  to  cause 
its  separation  is  outward  rotation  of  the  tibia,  which  motion  takes  place  toward 
the  end  of  flexion,  and  when  this  motion  is  very  forcible  the  internal  semilunar 
cartilage  is  very  liable  to  be  torn  from  its  attachments,  or  forcibly  compressed 
between  the  two  articular  surfaces,  so  that  separation  from  its  attachments 
or  a  radiating  fracture  occurs.  Whether  the  less  range  of  motion  enjoyed 
by  the  internal  cartUage  has  anything  to  do  with  the  frequency  of  its  involvement 
cannot  be  definitely  stated.  The  accident  usuaUy  occurs  during  moderate 
flexion  in  young  adults  while  engaged  in  outdoor  exercises. 

Symptoms. — WhUe  engaged  in  some  exercise  the  patient  twists  the 
knee  suddenly  and  experiences  sharp  pain  in  the  knee;  this  may  be  so  se- 
vere as  to  cause  fatntness  or  may  be  slight ;  it  is  followed  by  the  impairment  of 
movement  at  the  joint,  by  the  occurrence  of  an  acute  sjTiovitis,  in  most  cases 
the  effusion  containing  blood,  and  local  tenderness  over  the  seat  of  the  torn 
semilunar  cartilage.  If  the  injury  occurs  by  outward  rotation  of  the  leg,  or 
if  the  leg  is  fixed  by  inward  rotation  of  the  body  at  the  knee,  the  mner  semilunar 
cartilage  is  injured  and  vice  versa;  in  all  cases  the  knee  is  considerably  flexed 
when  the  injury  occurs. 

The  immediate  results  of  the  injury  disappear  under  appropriate  treatment 


NON -TUBERCULOUS  KNEE-JOINT  DISEASE.  455 

when  there  is  no  displacement  of  the  cartilage,  when,  however,  this  occurs 
the  patient  finds  that  he  is  unable  to  extend  the  leg  on  account  of  locking  of 
the  joint,  and  it  is  often  necessary  to  reduce  the  cartilage  under  anesthesia. 

Following  the  acute  attack  the  patient  finds  that  the  joint  is  weakened, 
that  he  is  unable  to  place  the  knee  in  certain  degrees  of  flexion  with  rotation  of 
the  leg  without  the  displacement  recurring,  so  that  he  becomes  careful  to  avoid 
these  movements. 

The  cartilage  after  injury  may  not  be  displaced,  and  with  appropriate 
treatment  the  torn  edges  may  unite;  in  the  greater  number  of  cases  the 
cartilage  is  displaced  and  acts  as  a  wedge  in  the  joint,  preventing  full  exten- 
sion of  the  leg.  In  this  class  of  cases  an  anesthetic  is  sometimes  necessary 
for  reduction.  Very  often  the  displaced  cartilage  may  be  felt  beneath  the 
skin.  After  repeated  attacks  the  process  of  reduction  becomes  familiar  to 
the  patient.  This  consists  in  full  flexion,  then  inward  rotation  of  the  leg 
if  the  external  semilunar  cartilage  is  involved,  and  outward  rotation  if  the 
internal  cartilage  is  displaced;  while  this  is  being  done,  efforts  should  be  made 
to  separate  the  joint  surfaces  as  far  as  possible,  and  while  pressure  is  exerted 
over  the  position  of  the  displaced  cartUage  the  leg  should  be  quickly  but  not 
forcibly  extended.  After  repeated  attacks  a  chronic  effusion  results,  there 
is  moderate  impairment  of  function  at  slight  lateral  motion,  and  some  laxity 
of  the  entire  joint  structures. 

Treatment. — In  the  acute  cases  in  which  no  displacement  of  the  car- 
tilage has  occurred  attempts  should  be  made  to  obtain  union  by  immobiliza- 
tion for  four  to  six  weeks,  and  at  the  same  time  massage  of  the  calf  and  thigh 
muscles  should  be  given.  At  the  end  of  this  time  the  patient  may  be  allowed 
to  use  the  limb,  which,  however,  should  be  supported  by  an  elastic  knee-cap. 
In  some  cases  it  is  well  to  place  some  firm  material  in  the  posterior  portion 
of  the  knee-cap  to  prevent  full  flexion. 

If  the  cartilage  is  displaced  and  thereby  prevents  free  motion  in  the 
joint,  it  may  be  reduced  by  the  method  given  above,  after  which  the  limb 
should  be  immobilized  and  at  the  end  of  six  weeks  the  patient  may  be  al- 
lowed to  walk  with  Marsh  apparatus  or  other  appropriate  support,  and 
always  bearing  in  mind  to  avoid  those  movements  which  will  cause  a  recur- 
rence of  the  dislocation. 

If  the  dislocation  is  impossible  to  reduce,  or  has  existed  for  a  long  time, 
or  if  the  attacks  become  so  frequent  as  to  render  the  function  of  the  joint 
much   impaired,    operative    treatment    is   advisable.     This   consists   in   open- 


456  ORTHOPEDIC  SURGERY. 

ing  the  joint  under  aseptic  precautions  by  a  transverse  or  vertical  incision  to 
either  side  of  the  patella.  If  the  cartilage  is  only  separated  from  its  periph- 
eral attachment  to  the  tibia,  or  if  there  exists  only  a  radiating  tear,  so  that 
very  little  displacement  occurs,  it  may  be  sutured  in  place  with  catgut.  If 
a  separation  exists  between  the  cartilage  and  the  tibia,  or  a  portion  of  carti- 
lage projects  into  the  joint,  of  if  any  of  the  portion  involved  looks  diseased, 
then  the  involved  portion  should  be  removed.  If  necessary,  the  entire  car- 
tilage may  be  removed.  After  thorough  exploration  of  the  joint  the  wound 
should  be  sutured,  a  sterile  dressing  applied,  and  the  joint  immobilized  for 
six  to  eight  weeks.  During  this  time  massage  should  be  used  to  keep  up  the 
tone  of  the  muscles,  and  at  the  end  of  this  time  the  patient  may  be  slowly 
allowed  to  take  passive  motion.  After  a  time  use  of  the  limb  should  be  en- 
couraged. 

Results  of  Partial  or  Total  Excision  of  a  Semilunar  Cartilage. — 
Partial  or  total  excision  of  a  semilunar  cartUage  is  generally  followed  by  good 
functional  results.  Joints  in  which  the  full  range  of  motion  was  not  possible 
without  a  dislocation  occurring  leave  full  extension  and  flexion  without  diffi- 
culty. The  tone  of  the  muscles  improves;  the  feeling  of  uncertainty  and 
weakness  gradually  disappears,  so  that  after  a  time  the  joint  becomes  very 
useful,  trustworthy,  and  functionally  perfect. 

Dislocation  of  the  Patella. 

Synonym. — Slipping  pateUa. 

Etiology. — Dislocation  of  the  patella  may  be  congenital;  may  be  due 
to  a  lax  condition  of  the  quadriceps  extensor  muscle;  to  elongation  of  the 
patellar  tendon;  to  direct  traumatism;  to  faulty  development  of  the  condyles 
or  pateUa;  to  genu  valgum,  and  occasionally  to  sudden  contraction  of  the 
extensor  muscles  of  the  thigh. 

In  dislocation  the  patella  may  be  displaced  outward,  inward,  down- 
ward, upward,  and  vertically.  The  outward  dislocation  is  the  most  frequent 
form. 

Congenital  dislocation  of  the  pateUa  is  usually  seen  in  conjunction  with 
congenital  genu  recurvatum,  and  occasionally  with  congenital  genu  valgum 
The  position  of  the  patella  in  these  cases  may  be  upward  or  outward.  When 
upward,  there  is  usually  a  lengthening  of  the  patellar  tendon;  when  outward, 
there  may  be  a  faulty  development  of  the  external  condyle  or  marked  genu 
valgum. 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  457 

The  majority  of  cases  of  dislocation  of  tlie  patella  due  to  a  lax  condi- 
tion of  the  quadriceps  extensor  muscle  occurring  during  adolescence,  usually 
in  girls  with  poor  muscular  development.  The  patella  in  these  cases  is  usu- 
ally dislocated  outward. 

Dislocation  of  the  patella  due  to  elongation  of  the  patellar  tendon  is 
usually  seen  in  conjunction  with  a  generally  relaxed  condition  of  the  knee- 
joint,  and  in  some  cases  other  joints  may  be  involved.  The  patella  is  always 
displaced  upward,  and  at  times  may  be  upward  and  outward.  This  elonga- 
tion of  the  tendon  may  follow  an  attack  of  hemiplegia,  paraplegia,  or  anterior 
poliomyelitis. 

A  large  percentage  of  cases  of  dislocation  of  the  patella  is  due  to  direct 
traumatism.  A  person  falling  on  the  knee  and  striking  the  outer  edge  of  the 
patella  may  receive  an  inward  dislocation  of  the  patella  and  vice  versa. 
Malgaigne  reports  a  case  of  outward  dislocation  of  the  patella  due  to  a  cav- 
alryman striking  his  knee  against  that  of  an  opponent  while  riding  past  him. 

Faulty  development  of  the  condyles  or  patella  predisposes  to  the  production 
of  the  dislocation,  by  rendering  the  planes  of  the  articular  surfaces  less 
pronounced,  and  thereby  allowing  them  to  slide  by  each  other  with  ease. 

Weimuth  in  a  report  of  66  cases  states  that  20  are  due  to  genu  valgum.  In 
this  condition  the  line  of  action  of  muscular  contraction  of  the  quadriceps  extensor 
muscle  is  in  a  line  outside  normal  and  near  the  external  condyle,  so  that  it 
may  be  readily  seen  what  part  this  condition  has  in  the  causation  of  dislocation 
of  the  patella.     The  position  of  the  patella  in  this  condition  is  always  outward. 

Occasionally  sudden  forcible  contraction  of  the  quadriceps  extensor  muscle 
causes  dislocation  of  the  patella.  This  especially  occurs  in  football-players, 
wrestlers,  etc.,  when  sudden  contraction  occurs,  when  the  knee  is  flexed  and 
the  leg  is  rotated  outward.  It  is  sometimes  seen  in  runners.  The  author 
recalls  a  case  of  double  dislocation  of  the  patella  outward  in  a  boy  eighteen 
years  old  in  whom  the  condition  occurred  repeatedly  when  running. 

As  a  result  of  the  dislocation  the  capsule  is  torn  to  a  considerable  extent 
on  the  side  opposite  to  which  the  displacement  occurs.  In  outward  disloca- 
tion the  inner  side  of  the  capsule  is  torn  along  its  anterior  surface,  the  edges 
of  the  tear  and  the  facial  prolongations  of  the  vastus  internus  are  rendered 
tense,  while  on  the  outside  the  capsule  is  thrown  together  in  folds  which  can 
be  felt  beneath  the  skin.  The  knee  is  flexed,  the  leg  rotated  outward,  and 
at  times  to  relieve  the  tension  on  the  quadriceps  extensor  muscle  there  may 
be  flexion  at  the  hip.     The  patella  is  visible  and  palpable  over  the  epicondyle 


45S  ORTHOPEDIC  SURGERY. 

and  is  firmly  held  in  this  position.  The  condition  of  the  capsule  and  position 
does  not  occur  when  the  dislocation  is  due  to  laxity  of  the  patellar  ligament 
or  quadriceps  extensor  muscle.  When  due  to  the  last  two  causes,  the  capsule 
is  rarely  torn;  and  when  the  knee  is  in  full  extension,  the  patella  can  usually 
be  carried  over  the  external  condyle  with  but  little  effort. 

In  vertical  dislocation  of  the  patella  the  displacement  is  a  continuation 
around  a  vertical  axis  of  a  lateral  dislocation,  so  that  the  outer  edge  in  outward 
dislocations  and  the  inner  edge  in  inward  dislocations  are  anterior  and  the 
cartilaginous  surface  of  the  patella  faces  outward.  The  dislocation  may 
continue  around  a  vertical  axis  until  the  surfaces  are  reversed  from  their  normal 
position. 

Symptoms. — Following  one  of  the  dislocations  enumerated  above  there 
is  during  the  first  attack  sharp  pain  around  the  knee,  accompanied  by  an  audible 
click,  inability  to  use  the  leg,  and  the  characteristic  deformity.  After  reduction 
there  follows  an  acute  synovitis,  which  rapidly  subsides  under  appropriate 
treatment,  leaving  a  joint  that  is  liable  to  subsequent  attacks,  and  which  is 
not  so  strong  as  its  fellow.  A  repetition  of  attacks  may  occur,  so  that  the  function 
is  greatly  impaired.  When  the  dislocation  results  from  a  lax  condition  of 
the  joint  structures,  there  is  practically  little  or  no  reaction. 

Prognosis. — The  most  unfavorable  result  of  dislocation  of  the  patella 
is  its  liability  to  recurrence  and  the  formation  of  a  chronic  synovitis.  In  most 
instances  the  patella  can  be  kept  from  slipping  by  appropriate  apparatus,  the 
one  drawback  of  which  is  its  constant  presence  and  limitation  of  the  motions 
of  the  joint.  After  repeated  attacks  there  results  a  chronic  synovitis,  lax  condi- 
tion of  the  joint  structures,  the  formation  of  loose  bodies  from  the  edges  of 
the  capsule,  and  a  functionally  imperfect  joint.  Measures  for  overcoming 
the  cause  and  operative  treatment  offer  the  best  chances  of  success. 

Treatment. — In  congenital  dislocations  of  the  patella  if  apparatus  fail 
to  hold  it  in  its  proper  position  it  may  be  necessary  to  replace  the  insertion 
of  the  patellar  tendon  on  the  tubercle  of  the  tibia  or  to  reef  the  capsule.  This 
should  not  be  delayed  later  than  the  sixth  year  for  fear  that  the  pressure  caused 
on  the  condyle  might  tend  to  faulty  development.  In  cases  due  to  lax  ligaments 
or  poorly  developed  muscles,  massage,  electricity,  hot  air,  and  exercise  should 
be  used,  in  conjunction  with  suitable  apparatus,  to  increase  the  strength  of  the 
ligaments  and  the  development  of  the  muscles. 

In  recent  cases  due  to  other  causes  after  reduction  the  entire  limb  should 
be  immobilized  for  two  to  three  weeks  and  passive  motion  and  massage  used 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  459 

at  the  end  of  seven  days.  When  the  patient  is  allowed  to  use  the  limb,  the 
knee  should  be  protected  by  an  elastic  bandage  or  knee-cap.  These,  however, 
are  not  as  useful  in  preventing  recurrence  as  the  apparatus  advised  by  Bradford, 
which  consists  in  two  pads  alongside  of  the  patella  which  are  held  in  place 
by  steel  bands  running  about  the  thigh  and  leg. 

The  reduction  of  a  dislocated  patella  is  accomplished  by  flexion  of  the 
thigh  upon  the  abdomen  and  by  extension  at  the  knee-joint;  this  relaxes  the 
quadriceps  extensor  muscle,  and  then  by  manipulation  the  patella  is  pushed 
into  its  normal  position.  Some  patients  who  have  habitual  dislocation  of 
the  patella  are  able  to  reduce  it  themselves  with  very  little  inconvenience.  The 
vertical  dislocations  are  often  difficult  of  reduction,  usually  requiring  anesthesia 
and  frequently  operative  interference. 

The  operation  consists  in  making  a  longitudinal  incision  alongside  the 
patella  on  the  opposite  side  to  which  displacement  occurs;  retracting  the 
edges  of  the  wound,  and  excising  an  oval  shaped  piece  of  the  capsule, 
or  in  making  a  reef  in  the  capsule  sufficient  to  prevent  a  recurrence  of 
the  deformity.  It  is  not  necessary  to  open  the  synovial  membrane.  The 
edges  of  the  capsule  can  be  united  by  mattress  sutures  of  chromicized 
catgut  or  silk.  The  skin  wound  should  be  closed  without  drainage,  a 
sterile  dressing  applied,  and  the  limb  immobilized  for  four  to  six  weeks, 
when  passive  motion  may  be  tried  and  the  patient  encouraged  to  use  the 
limb.  When  the  condition  is  due  to  genu  valgum,  the  cure  of  the  displacement 
will  depend  upon  the  result  of  osteotomy  for  the  correction  of  the  deformity. 
When  the  condition  results  from  the  traction  of  the  extensors  action  out  of 
the  proper  line,  the  spine  of  the  tibia  may  be  chiseled  off  and  moved  to  either 
side  according  to  the  desired  line  of  traction  wanted.  In  vertical  dislocation 
where  the  patella  is  completely  reversed  it  may  be  impossible  to  replace  the 
patella,  making  excision  necessary. 

Rudimentary  Patella. 

Rudimentary  patella  is  usually  associated  with  some  congenital  defect 
about  the  knee-joint.  This  may  consist  of  a  faulty  development  of  the  quad- 
riceps extensor  muscle,  a  genu  valgum  or  recurvatum,  or  subluxation  of  the 
upper  end  of  the  tibia.  At  times  the  patella  may  be  absent  or  so  small  at 
birth  as  to  entirely  escape  observation.  A  rudimentary  or  absent  patella  ren- 
ders the  joint  very  weak,  there  being  usually  impairment  of  extension. 

Treatment. — This  consists  in  treatina;  the  associated  condition.     Efforts 


460  ORTHOPEDIC  SURGERY. 

should  be  made  to  overcome  the  faulty  development  of  the  quadriceps  exten- 
sor muscle  by  electricity,  massage,  and  passive  motion.  If  genu  valgum  or 
genu  recurvatum  are  present,  they  should  be  corrected.  jNIost  cases  require 
some  supporting  apparatus. 

Snapping  Knee. 

Synonyms. — Schnellendes  or  Federndes  knee;    Genou  a  Ressort. 

Snapping  knee  is  that  condition  of  the  knee-joint  which  consists  in  a 
partial  displacement  backward  of  the  head  of  the  tibia,  when  the  leg,  in  the 
act  of  extension,  goes  beyond  i6o  degrees,  and  is  accompanied  by  a  sudden 
jerk  or  snap  and  at  times  an  audible  click,  and  by  outward  rotation  of  the 
tibia.  The  jerk  or  snap  cannot  be  made  during  passive  extension.  The 
majority  of  cases  occur  in  children,  but  a  few  are  seen  in  adults. 

Etiology. — The  exact  cause  is  not  known.  There  is  always  present 
a  lax  condition  of  the  ligaments,  and  this,  combined  with  sudden  muscular 
action,  may  account  for  the  condition.  It  is  thought  by  some  to  be  due  to 
some  abnormality  in  the  movement  of  the  external  semilunar  cartilage,  and 
that  it  is  caught  between  the  articular  surfaces,  and  as  the  extension  goes 
beyond  i6o  degrees  it  is  freed,  producing  the  jerk  and  at  times  the  audible 
click.  In  some  cases  there  is  the  previous  history  of  trauma,  dating  back 
several  years.  As  the  normal  limit  of  extension  is  checked  by  the  posterior 
crucial  ligaments  it  was  thought  by  Thiem  to  be  due  to  a  rupture  of  these 
ligaments.  Spasm  of  the  flexor  muscles  and  slipping  of  the  biceps  tendon 
have  been  considered  in  the  causation. 

Symptoms. — There  may  be  a  history  of  injury,  but  in  most  cases  while 
walking  the  patient  notices,  on  extending  the  leg,  a  sudden  jerking  move- 
ment, which  is  usually  accompanied  by  pain.  The  patient,  however,  is  gener- 
ally able  to  walk  along  without  difficulty.  The  deformity,  which  is  rare,  is 
displacement  of  the  head  of  the  tibia  backward,  and  is  always  reduced  with- 
out difificulty. 

Prognosis. — In  children  the  prognosis  is  favorable;  in  adults  the  con- 
dition usually  becomes  chronic  but  causes  little  inconvenience  when  supported 
by  suitable  apparatus. 

Treatment. — When  the  condition  can  be  ascribed  to  laxity  of  the  liga- 
ments, massage,  electricity,  and  passive  motion  are  beneficial.  This  should 
be  combined  with  a  suitable  elastic  bandage,  and  in  some  cases  a  brace  will 
be  found  necessary. 


NON-TUBERCULOUS  KNEE-JOINT  DISEASE.  461 

Elongation  of  the  Patellar  Tendon. 

Etiology. — An  abnormal  length  of  the  patellar  tendon  may  be  congenital, 
it  may  be  associated  with  a  laxity  of  the  other  ligaments,  it  may  be  due  to  trau- 
matism, and  is  sometimes  seen  in  anterior  poliomyelitis. 

Symptoms. — The  symptoms  are  those  due  to  a  weak  and  lax  joint. 
There  is  early  fatigue  on  exertion,  at  times  disability;  in  walking  up-stairs 
the  patient  has  difficulty  in  raising  the  leg  sufficiently  high  when  the  knee  is 
semiflexed,  and  in  walking  on  a  level  supplements  the  muscular  force  of  ex- 
tension by  an  increased  effort  at  swinging  the  thigh  forward.  The  patella 
is  usually  displaced  upward,  and  with  the  leg  in  full  extension  it  can  be  dis- 
placed laterally  to  a  marked  degree.  It  is  very  often  the  cause  of  complete 
dislocation  of  the  patella.  In  some  instances  there  is  considerable  lateral 
mobility  of  the  knee-joint,  due  to  the  general  lax  condition  of  all  the 
ligaments. 

Treatment. — This  consists  in  massage  and  electricity  to  increase  the 
muscular  tone  and  strengthen  the  ligaments  and  a  brace  to  prevent  lateral 
mobility  of  the  joint  or  lateral  displacement  of  the  patella.  In  some  cases 
operative  interference  is  advisable.  This  is  so  if  the  condition  is  not  asso- 
ciated with  laxity  of  the  other  ligaments.  The  operation  consists  in  short- 
ening the  ligament  or  in  chiseling  off  the  tubercle  of  the  tibia  and  moving  it 
to  a  lower  position. 

Rupture  of  the  Quadriceps  Extensor  and  Patellar  Tendons. 

Rupture  of  the  quadriceps  extensor  and  patellar  tendons  is  of  more  fre- 
quent occurrence  than  is  generally  supposed.  It  may  vary  in  position  and 
degree. 

Etiology. — The  cause  of  rupture  is  usually  muscular  action,  but  may  be 
due  to  direct  injury  or  disease.  When  due  to  muscular  action,  it  usually  follows 
a  sudden  contraction  to  prevent  falling,  or  may  follow  a  fall  on  the  feet  when 
the  knee  is  semiflexed.  The  rupture  may  rarely  be  due  to  direct  violence. 
Vulpius  reports  two  cases  due  to  disease ;  in  the  one  there  was  fatty  degeneration 
of  the  tendon,  in  the  other  there  was  sarcoma  of  the  head  of  the  tibia,  so  that 
the  patellar  ligament  was  torn  off  the  spine  of  the  tibia. 

Rupture  of  the  quadriceps  extensor  tendon  takes  place  most  frequently 
at  its  attachment  to  the  patella,  rarely  in  the  middle  of  the  tendon,  but  at  times 
it  occurs  just  above  the  muscular  expansion.  Rupture  of  the  patellar  tendon 
takes  place  most  frequently  at  the  attachment  to  the  tibia,  next  in  order  at  the 


462  ■  ORTHOPEDIC  SURGERY. 

attachment  to  the  patella,  and  very  rarely  in  the  middle.  The  more  frequent 
condition  is  the  separation  of  the  tubercle  of  the  tibia,  leaving  the  tendon  intact. 

Symptoms. — Usually  following  sudden  forcible  contraction  of  the  quad- 
riceps extensor  muscle  the  patient  experiences  a  sharp  pain  at  the  seat  of 
rupture,  falls  to  the  ground,  and  is  unable  to  get  up  or  fully  extend  the  leg. 
Examination  shows  a  gap  in  the  tendon  varv'ing  from  one-fourth  to  one  inch 
in  width;  if  the  patellar  ligament  is  torn,  the  patella  may  be  drawn  upward  one  to 
three  inches.  Following  the  injur}'  there  results  an  acute  s^Tl0^•itis,  which 
may  entirely  mask  the  symptoms  for  a  time.  When  the  patellar  tendon  is 
ruptured,  the  capsule  of  the  joint  may  or  may  not  be  torn.  This  depends  upon 
the  position  of  the  rupture,  but  in  most  cases  the  capsule  is  torn  except  when 
the  rupture  takes  place  near  its  attachment  to  the  tibia. 

Prognosis. — Usually  the  torn  ends  of  the  tendon  are  curled  up  and 
away  from  each  other  and  on  account  of  the  separation  firm  fibrous  union 
rarely  takes  place  unless  operative  treatment  is  instituted.  \Mien  treated 
by  mechanical  means  there  usually  results  impairment  of  extension,  combined 
with  a  weak  joint  and  muscular  atrophy. 

Treatment. — This  may  be  divided  into  mechanical  and  operative.  The 
mechanical  treatment  consists  in  immobilization  on  a  posterior  wire  splint 
in  the  position  of  extension  and  in  elevation  of  the  leg  so  as  to  relax  the  quadri- 
ceps extensor  muscle.  The  s)^ao^•itis  may  be  treated  by  compression.  If 
the  rupture  is  in  the  patellar  tendon,  efforts  may  be  made  to  draw  it  down  in 
place  by  means  of  adhesive  plaster  passed  above  it  to  make  traction.  At 
the  end  of  two  weeks  massage  should  begin,  and  at  the  end  of  five  to  six  weeks 
the  patient  may  be  allowed  on  crutches,  ^^^len  the  rupture  is  in  the  quadriceps 
extensor  tendon,  attempts  to  bring  the  torn  ends  together  are  futile,  and  the 
best  result  that  can  possibly  be  hoped  for  is  moderate  fibrous  union  unless 
operative  treatment  is  adopted.  This  consists  in  exposing  the  torn  ends  by 
a  suitable  incision  and  suturing  the  ends  by  means  of  chromicized  catgut.  If 
the  attachment  of  the  patellar  tendon  is  torn  off,  it  may  be  held  in  place  by 
periosteal  sutures,  or  a  nail  may  be  used  to  anchor  it  in  position.  The  wound 
is  closed  without  drainage,  a  sterile  dressing  employed,  and  a  plaster-of-Paris 
bandage  applied  from  toes  to  groin.  The  limb  should  be  kept  elevated,  massage 
begun  at  the  end  of  two  weeks,  crutches  used  at  the  end  of  four  weeks,  and 
the  operation  should  give  a  perfect  functional  result. 


CHAPTER  VIII. 
TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  AND  TARSUS. 

Tuberculous  Disease  or  the  Ankle-joint. 

This  is  a  chronic  tuberculous  affection  of  the  ankle-joint,  having  in 
the  majority  of  cases  its  primary  focus  in  the  astragalus  or  calcaneum.  It 
is  next  in  order  of  frequency  to  that  of  the  knee  and  is  relatively  more  common 
in  adolescence  and  early  adult  life  than  similar  disease  of  the  hip  and  knee. 

Etiology, — Added  to  a  constitutional  predisposition,  the  disease  is  usually 
excited  by  traumatism  and  by  exposure  to  dampness  or  cold.  When  we  consider 
that  the  ankle-joint  is  more  frequently  the  seat  of  injury  than  any  other  joint 
in  the  body,  it  is  remarkable  that  it  is  not  more  frequently  affected  by  tuberculous 
osteitis. 

Pathology. — The  pathologic  changes  met  in  tuberculous  ankle-joint  dis- 
ease are  similar  to  the  conditions  found  in  other  joints.  The  disease  may. 
have  its  primary  focus  in  the  lower  end  of  the  tibia,  fibula,  or  any  bone  of  the 
tarsus.  While  older  writers  claim  that  the  disease  may  be  primary  synovial, 
the  investigations  of  Nichols  lead  one  to  believe  that  with  more  thorough  search 
of  the  osseous  portions  of  the  ankle  the  percentage  of  primary  synovial  involve- 
ment will  be  reduced  to  a  minimum.  On  account  of  the  extensive  communica- 
tion of  the  synovial  membrane  of  the  joints  of  the  foot  and  their  proximity 
to  the  ankle,  extension  following  primary  involvement  of  the  tarsal  bones, 
may  lead  quickly  to  invasion  of  several  joints,  and  at  times  the  anlde-joint. 
In  this  case  the  bones  of  the  foot  and  ankle  become  rapidly  surrounded  by 
masses  of  tuberculous  material,  rendering  the  situation  of  the  primary  focus 
very  difficult  and  in  most  cases  impossible  to  find.  Abscess  formation  is  more 
common  in  ankle-joint  disease  than  in  other  joints. 

Statistics. — In  5680  cases  treated  at  the  Orthopedic  Department  of  the 
Hospital  of  the  University  of  Pennsylvania,  there  were  44  cases  of  this  aft'ection. 
INIondan's  report  of  117  cases  from  Ollier's  clinic  states  that  the  disease  was 
primarily  osseous  in  114,  primarily  synovial  in  3,  and  doubtful  in  25  cases. 
Hann  reported  907  cases  collected  from  various  statistics  (Audry,  Konig,  Mondan, 
Miinch,  Spengler,  Vallas)  and  from  some  cases  observed  at  v.  Bruns'  clinic. 

463 


464 


ORTHOPEDIC  SURGERY 


Of  these,  the  disease  was  primarily  osseous  in  68.7  per  cent.,  primarily  synovial 
in  31  per  cent.,  and  in  74  cases  it  was  impossible  to  determine  the  original  focus. 
In  his  report  of  704  cases  treated  at  Tubingen,  covering  a  period  of  fifteen 
years,  there  were  309  cases  in  which  the  ankle-joint  was  diseased,  the  primary 
focus  being  in  the  internal  malleolus  in  11  cases,  in  the  external  malleolus  in 
7  cases,  in  both  malleoli  in  5  cases,  and  the  astragalus  was  primarily  involved 
in  116  cases.  The  remaining  49  per  cent,  were  of  synovial  origin.  In  16  cases 
the  disease  was  secondary  to  a  focus  in  the  os  calcis,  and  in  5  cases  the  os  calcis 
and  astragalus  were  conjointly  involved.  Vallas,  in  reporting  71  cases  operated 
on  by  Oilier,  states  that  the  original  focus  was  in  the  astragalus  in  22,  in  the 
calcaneum  in  13,  the  scaphoid  in  3,  the  cuboid  in  i, 
in  the  malleoli  in  9,  and  was  primarily  synovial  in 
23  cases. 

The  tendency  to  abscess  formation  is  much 
greater  in  ankle-joint  disease  than  in  that  of  the  hip 
or  knee.  Prendlesburger's  statistics  give  87  per  cent, 
and  Gibney  83  per  cent. 

Symptoms. — The  onset  of  this  disease  is  very 
insidious,  but  the  cardinal  symptoms  of  chronic  joint 
disease  may  be  early  recognized.  These  are  muscular 
spasm,  atrophy,  lameness,  the  peculiar  attitude  of  the 
limb  in  walking  and  standing,  pain,  swelling,  and  the 
occurrence  of  abscesses.  Lameness  is  an  early 
symptom,  at  first  a  little  soreness  or  stiffness  in  the  joint  after  exercise,  later 
increasing  in  severity,  and  aggravated  by  walking  or  motion.  The  swelling 
at  first  appears  at  the  sides  of  the  extensor  tendons  and  later  behind  and 
below  the  malleoli,  obliterating  the  normal  outlines  of  the  joint.  At  first  the  foot 
is  movable,  but  usually  held  in  extension,  adduction,  and  inversion ;  later  it  be- 
comes fixed  in  this  position.  No  lateral  displacement  occurs  except  when  the  joint 
structures  are  disorganized.  Pain  is  not  a  constant  symptom,  but  the  entire 
joint  may  be  exquisitely  sensitive  to  pressure  and  accompanied  by  "night  cries." 
When  suppuration  occurs,  the  abscesses  point  in  the  direction  of  least  resist- 
ance, either  anterior  or  posterior  to  the  malleoli. 

Disease  of  the  astragalus  is  usually  classified  with  ankle-joint  disease,  as  in 
only  8  instances  out  of  170  cases  of  disease  of  the  astragalus  did  the  ankle-joint 
remain  intact  (Hahn).  While  the  symptoms  at  first  may  differ  slightly  from 
those  of  ankle-joint  disease,  the  latter  is  so  soon  involved  that  differentiation 


Fig.  359. — Ankle-joint  Disease 
(Barwell). 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  AND  TARSUS.        465 


becomes  impossible.  When  secondary  involvement  does  not  occur,  the  swelling 
is  below  the  ankle-joint  and  midway  between  the  malleoli.  Flexion  and 
extension  are  generally  not  impaired. 

Diagnosis. — The  disease  can  be  easily  recognized  by  attention  to  the 
foregoing  symptoms,  but  the  affection  must  be  distinguished  from  tenosynovitis, 
functional  affections,  acute  articular  rheumatism,  infectious  arthritis,  and  sprains. 

In  tenosynovitis  the  swelling  and  tenderness  are  localized  along  the  course  of 
the  tendons.     Pain  is  only  present  on  motion ; 
there  is  no  muscular  spasm  or  deformity,  and 
in  most  cases  crepitation  can  be  felt  over  the 
affected  tendons  on  voluntary  motion. 

Functional  affections  may  simulate  to 
some  extent  tuberculous  ankle-joint  disease, 
but  are  distinguished  from  the  latter  by  the 
absence  of  muscular  spasm,  of  swelling,  local 
signs  of  inflammation,  and  by  the  fact  that  all 
sjanptoms  are  subjective. 

In  sprains  the  symptoms  are  acute,  there 
is  the  history  of  injury,  swelling  is  always  be- 
low and  behind  the  malleoli ;  there  is  no  de- 
formity or  passive  limitation  of  motion. 

Acute  articular  rheumatism  is  differen- 
tiated by  the  presence  of  fever,  involvement 
of  other  joints,  and  its  subsidence  under  the 
salicylates. 

In  infectious  arthritis  there  is  usually  the 
history  of  a  wound  or  a  septic  process  else- 
where, temperature,  lymphangitis,  local  heat, 
and  rapid  onset. 

Prognosis. — The  course,  duration,  and  termination  are  partly  influenced 
by  the  age  of  the  individual.  In  children  recovery  is  the  rule  without  surgical 
interference,  while  in  adults  operative  measures  are  necessary  in  many  cases. 
The  final  result  in  children  is  good.  Under  conservative  measures  children 
very  often  retain  considerable  motion  at  the  ankle-joint,  especially  if  the  astra- 
galus is  not  involved;  and  when  this  is  diseased  the  motion  at  the  ankle  is 
supplemented  by  the  joints  of  the  foot.  Shortening  is  not  marked  and  rarely 
amounts  to  more  than  2  to  |  of  an  inch. 

31 


Fig.  360. — TtJBERCDXous  Ankle-joint 
Disease,  -svith  Meningitis. 


466 


ORTHOPEDIC  SURGERY. 


Treatment. — Tuberculous  disease  of  the  ankle-joint  in  most  cases  yields 
readily  to  conservative  treatment,  and  while  traction  is  inapplicable  on  account 
of  the  anatomic  peculiarities  of  the  joint,  the  other  two  principles  of  conser- 
vative treatment,  fixation  and  protection,  are  followed  by  very  gratifying  results. 
Conservative  treatment. — In  the  acute  stages  it  may  be  wise  to  put 
the  patient  to  bed  and  elevate  the  limb  if  much  swelling  is  present;  and  while 
children  do  well  in  bed  for  a  long  time,  adults  improve  more  rapidly  in  the 
open  air.     Fixation  should  be  secured  by  the  application  of  a  plaster-of-Paris 

splint  reaching  from  the  toes  to  just  below 
the  knee,  and  in  some  cases  it  may  be  ad- 
visable to  fix  the  knee-joint.  Protection  is 
afforded  by  a  high  sole  on  the  sound  foot 
and  crutches.  No  weight  should  be  borne 
on  the  diseased  side,  so  in  some  cases  the 
possibility  of  this  can  be  guarded  against 
by  the  use  of  a  splint  which  transfers  all 
the  weight  to  the  tuber  ischium.  A 
Thomas  knee  splint  is  very  suitable  for 
this  purpose.  \'ery  often  patients  are 
not  seen  until  the  deformity  has  become 
well  marked.  In  these  cases  the  de- 
formity may  be  corrected  gradually  or 
rapidly.  It  is  corrected  gradually  by  the 
successive  application  of  plaster-of-Paris 
bandages  from  the  toes  to  the  knee  every 
week.  After  one  or  two  weeks  the  mus- 
cular spasm  will  have  lessened  to  such  an 
extent  as  to  render  correction  painless  and  easy.  In  some  resistant  cases 
the  deformity  can  be  corrected  rapidly  under  anesthesia.  In  the  application 
of  plaster-of-Paris  and  other  splints  the  greatest  care  should  be  exercised  to 
keep  the  foot  and  ankle  in  good  position,  as  in  the  early  stages  deformity  is 
readily  corrected.  This  is  not  so  in  the  late  stages,  and  to  prevent  this  mal- 
position should  be  the  object  of  the  splints.  Plaster-of-Paris  is  the  best  ma- 
terial for  these  splints,  as  it  is  rapid  in  application,  fits  the  parts  accurately, 
and  can  readily  be  renewed.  A  new  bandage  should  be  applied  everj'  three 
to  four  weeks.  Verj^  good  results  have  followed  the  injection  of  iodoform 
glycerin  (lo  per  cent.)  directly  into  the  joint.     The  place  of  puncture  should 


Foster  Axkle  Brace. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  AND  TARSUS.        467 

be  at  the  sides  of  the  extensor  tendons.  As  abscesses  form  they  may  be  treated 
in  a  similar  manner.  Bier's  method  of  passive  congestion  may  be  used  in 
treating  tuberculous  ankle-joint  disease,  and  while  it  is  only  in  its  initial  stage, 
good  results  are  expected  of  it. 

Conservative  treatment  should  be  tried  in  children  as  long  as  the  patient's 
general  health  remains  good.  Abscesses  and  fistulas  often  heal  either  by  in- 
jection with  iodoform  emulsion  or  cureting  out  the  cavity  or  fistula.  Operative 
measures  are  to  be  considered  when  there  is  high  fever,  profuse  suppuration, 
evidences  of  failing  of  the  general  health,  or  the  appearance  of  tuberculosis 
of  other  organs.  Maas,  in  Konig's  clinic,  advised  operation  in  children  if 
at  the  end  of  two  months  marked  improvement  had  not  occurred.  In  adults 
conservative  treatment  does  not  give  as  good  results  as  in  children.  The  ap- 
pearance of  suppuration  is  a  positive  indication  for  operative  treatment. 

Operative  treatment. — Under  the  operative  treatment  are  classed, 
(i)  curetage;    (2)  resection;    and  (3)  amputation. 

1.  Curetage:  WhUe  the  cureting  of  sinuses  and  abscesses  in  children 
may  be  done  with  little  risk,  in  the  adult  the  results  are  not  so  good,  and  this 
procedure  is  often  followed  by  rapid  involvement  of  surrounding  structures 
and  occasionally  by  a  rapid  general  tuberculosis.  Very  often  by  this  method 
considerable  amounts  of  healthy  bone  are  removed  that  otherwise  might  not 
have  become  involved.  This  procedure  should  be  limited  to  children  and  to 
adults  until  the  stage  of  convalescence,  when  it  may  be  used  to  remove  sequestra 
and  tuberculous  sinuses.  It  is  contraindicated  in  adults  during  the  acute 
stage  of  the  disease. 

2.  Resection:  The  indications  for  resection  have  greatly  increased  and 
its  results  have  been  much  better  during  late  years.  Formerly  surgeons,  on 
account  of  the  poor  functional  results  obtained,  feared  to  remove  the  tuberculous 
area  thoroughly.  Of  late,  however,  any  method  which  completely  eradicates 
the  diseased  areas,  even  if  the  functional  results  are  not  satisfactory,  is  con- 
sidered preferable  to  amputation.  The  latter  is  advisable  when  the  patient's 
general  condition  ^^'ill  not  endure  a  prolonged  convalesence  and  when  the 
age  is  well  advanced.  Osier  considers  the  mortality  of  resection  at  5  per  cent, 
up  to  the  fifteenth  year;  at  10  per  cent,  between  twenty  and  twenty-five  j-ears, 
and  at  19  per  cent,  beyond  t^venty-five  years.  Other  contraindications  to 
resection  are,  rapidly  growing  tuberculosis  of  the  lungs,  amyloid  degeneration 
of  the  viscera,  very  marked  secondary  infection,  and  general  weakness. 

In  resection  a  better  functional  result  is  obtained  if  the  malleoli  are  pre- 


468  ORTHOPEDIC  SURGERY. 

served.  The  old  methods  of  resection  of  v.  Langenbeck  and  Bourgery  are 
no  longer  used,  on  account  of  the  great  amount  of  bone  sacrificed  and  the 
unstabUity  of  the  resulting  joint.  Konig's  method  preserves  the  malleoli. 
Kocher's  and  Lauenstein's  method  allows  the  entire  joint  to  be  inspected, 
as  the  joint  can  be  readily  dislocated  and  a  thorough  examination  of  diseased 
structure  is  possible.  Of  all  the  methods  used  from  time  to  time,  that  of  Kocher 
has  given  the  best  results.  It  is  as  follows:  Bleeding  may  be  controlled  by 
a  tourniquet.  A  curved  incision  is  made  on  the  external  surface  just  behind 
and  below  the  external  malleolus  and  is  carried  forward  from  the  tendo  Achillis 
to  the  extensor  tendons.  The  peroneal  tendons  are  cut  and  the  ends  secured. 
The  lateral  and  capsular  ligaments  are  divided.  The  foot  is  dislocated  in- 
ward, the  capsule  of  the  joint  incised,  and  the  cavity  thoroughly  inspected. 
All  diseased  tissue  should  be  thoroughly  removed.  The  astragalus  is  in  most 
cases  diseased  and  should  be  removed;  portions  of  the  tibia  may  require  re- 
moval. The  wound  may  be  closed,  but  it  is  advisable  in  most  cases  to  pack 
with  iodoform  gauze.  A  sterile  dressing  and  plaster-of-Paris  bandage  should 
then  be  applied  from  the  toes  to  the  knee,  attention  being  paid  to  keeping  the 
foot  at  right  angles  to  the  leg  and  mid-way  between  inversion  and  eversion. 
A  window  may  be  cut  through  the  plaster-of-Paris  splint  to  facilitate  dressing. 

3.  Amputation:  While  resection  may  be  considered  as  a  conservative 
operative  method,  in  many  cases  it  fails  and  is  contraindicated  by  the  develop- 
ment of  general  miliary  tuberculosis,  poor  general  condition,  age,  and  lack 
of  resisting  powers.     In  this  class  of  cases  amputation  is  necessary. 

As  this  radical  measure  is  called  for  by  the  urgent  condition  of  the  patient, 
the  chief  point  to  be  considered  is  the  removal  of  the  diseased  area  so  as  to 
shorten  convalescence.  To  do  this,  the  point  of  amputation  should  always 
be  in  healthy  tissue  and  the  stump  should  be  such  as  to  heal  by  primary  intention. 
The  method  of  amputation  is  left  to  individual  choice  and  may  be  found  in 
works  on  general  surgery. 

Statistics  on  treatment.  Under  conservative  treatment  Gibney  noted 
the  results  in  thirty  cases  as  follows: 

1.  The  minimum  duration  was  one  year. 

2.  The  maximum  duration  was  six  years. 

3.  The  average  duration  was  three  years  and  three  months. 

4.  The  average  time  under  treatment  was  one  year  and  three  months. 

5.  Extensive   suppuration   occurred   in  nineteen   cases. 

6.  Moderate  suppuration  occurred  in  six  cases. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  AND  TARSUS.        469 

7.  No  suppuration  occurred  in  five  cases. 

8.  Twenty  patients  recovered  without  any  limp  and  six  had  very  slight 
limp. 

9.  There  were  usually  shortening  and  atrophy  of  the  calf  muscles  when 
the  disease  occurred  in  children. 

10.  In  three  cases  there  was  resulting  deformity  in  the  foot. 

11.  There  were  two  deaths,  one  of  which  was  due  to  the  disease. 

12.  Six  patients  recovered  with  normal  motion,  eleven  with  practically 
normal  motion,  and  in  seven  the  motion  was  fair.  Ankylosis  occurred 
in  six  cases. 

The  most  valuable  statistics  of  cases  treated  by  resection  are  those  of 
Connor.  His  report  includes  108  cases  treated  by  resection.  In  47.37  per 
cent,  the  results  were  good;  in  10.53  P^^  cent,  there  were  failures;  24.21  per 
cent,  could  walk  without  limping;  and  6.32  per  cent,  could  walk  with  a  cane. 
Shortening,  while  present  in  all  the  cases,  was  slight  in  the  majority. 

Maas  reported  102  cases  from  Konig's  clinic.  Of  these,  87  were  operated 
on  by  Konig's  method,  in  48  astragalectomy  being  performed.  Forty-two 
of  these  cases  were  examined  at  a  late  period  after  the  operation  and  in  all 
the  functional  results  were  good,  there  being  no  tendency  to  deformity  or  weak- 
ness at  the  joint.  The  shortening  in  these  cases  averaged  3J  inches,  which 
was  in  marked  contrast  to  1 1  cases  operated  on  by  v.  Langenbeck's  method, 
in  which  the  shortening  averaged  5I  inches  and  only  one  recovered  with  a 
good  functional  result. 

Resection  of  the  astragalus,  which  is  usually  necessary  in  tuberculous 
disease  of  the  ankle-joint,  is  generally  followed  by  little  or  no  impairment  of 
function;  the  shortening  is  very  little  increased,  and  if  the  malleoli  are  not 
removed  the  results  are  good. 

Tuberculous  Disease  of  the  Tarsus. 

The  joints  of  the  foot  are  often  the  seat  of  tuberculous  disease  without 
similar  involvement  of  the  ankle-joint.  From  the  statistics  of  1231  cases  re- 
ported by  Hahn  the  frequency  of  involvement  of  the  bones  of  the  foot  and 
ankle  is  as  follows:  Calcaneus,  339  (25.9  per  cent.);  astragalus,  291  (23.6 
per  cent.);  cuboid,  154  (12.5  per  cent.);  scaphoid,  no  (8.9  per  cent.);  cunei- 
forms, 109  (8.8  per  cent.);  metatarsals,  no  (8.9  per  cent.);  malleoli,  96  (7.7 
per  cent.);    and  phalanges,  22  (1.7  per  cent.). 

On  account  of  the  proximity  of  the  joints  of  the  foot  disease  of  one  joint 


470  ORTHOPEDIC  SURGERY. 

is  rarely  self-limited, ,  but  spreads  rapidly  to  other  joints.  As  a  result  many 
of  the  tarsal  bones  are  affected  early,  and  the  entire  tarsus  and  surrounding 
structures  are  involved  early  and  converted  into  a  tuberculous  mass,  so  that  bony 
outlines  are  lost  and  it  soon  becomes  impossible  to  distinguish  the  primary 
seat  of  the  disease.  Hahn,  from  v.  Bruns'  clinic,  reports  170  cases  of  the  as- 
tragalus in  which  the  ankle-joint  remained  intact  in  only  8  instances;  and 
in  386  out  of  704  cases  limited  to  the  foot  and  reported  by  the  same  author, 
the  mediotarsal  joint  v\'as  affected  in  141  instances,  and  in  91  of  these  extension 
of  the  process  continued  to  other  joints;  in  46  the  ankle,  in  29  the  tarsometa- 
tarsal and  in  16  the  three  joints  were  involved.  In  only  50  instances  was  the 
disease  self-limited  to  the  joint  in  which  it  commenced.  Of  78  cases  of  in- 
volvement of  the  tarsometatarsal,  33  were  self-limited. 

The  calcaneum  is  the  most  frequently  involved  bone  of  the  foot.  It  is 
remarkable  on  account  of  the  large  sequestra  formed  and  on  account  of  the 
infrequency  of  joint  involvement;  the  calcaneo-astragaloid  joint  being  most 
frequently  attacked.  IMondan's  statistics  show  joint  involvement  in  26  of 
40  cases,  and  of  these  26  the  calcaneo-astragaloid  joint  was  involved.  Statistics 
from  V.  Bruns'  clinic  show  joint  involvement  in  87  of  200  cases  of  tuberculous 
disease  of  the  calcaneum. 

In  disease  of  the  calcaneum  the  swelling  of  the  soft  parts  is  limited  to 
the  heel  and  the  bone  is  thickened.  x\s  the  calcaneo-astragaloid  joint  becomes 
involved  the  swelling  extends  higher  and  more  forward  toward  both  malleolei, 
eversion  and  inversion  are  painful  and  attended  by  slight  muscular  spasm. 
Flexion  and  extension  are  not  altered. 

In  astragaloid  disease  the  swelling  occurs  either  below  the  malleolei  and 
simulates  primary  disease  of  the  os  calcis  with  involvement  of  the  calcaneo- 
astragaloid  joint,  or  if  the  focus  is  on  the  anterior  surface  the  swelling  first 
appears  on  the  dorsum  of  the  foot  just  beneath  the  ankle-joint  and  mid-way 
between  the  malleolei.  Usually,  however,  the  ankle-joint  becomes  involved 
very  early,  and  as  a  result  it  is  impossible  to  distinguish  the  condition  from 
primary  disease  of  the  ankle-joint. 

In  disease  of  the  cuboid  and  scaphoid  the  swelling  is  first  noticed  on  the 
inner  or  dorsal  surface  of  the  foot,  but  there  is  a  tendency  to  rapid  involvement 
of  the  base  of  the  four  last  metatarsals  and  the  anterior  surfaces  of  the  astragalus 
and  calcaneum.  The  disease  may  begin  in  the  first  metatarsal  or  internal 
cuneiform  bones  and  be  limited  to  these  two  for  some  time  on  account  of  the 
non-communication  of  the  joint  with  the  other  tarsal  joints. 


TUBERCULOUS  DISEASE  OF  THE  ANKLE-JOINT  AND  TARSUS.        471 

After  the  disease  has  advanced  to  a  certain  stage  it  is  practicaUy  impossible 
to  say  where  the  primary  focus  was  situated.  The  swelling  spreads  so  rapidly 
on  account  of  the  arrangement  of  the  mediotarsal  and  tarsometatarsal  joints 
that  very  soon  the  soft  parts  are  converted  into  a  mass  of  tuberculous  material 
which  eventually  destroys  the  outline  of  the  bones.  Abscesses  usually  occur 
and  may  rupture  on  the  inner  side,  generally  on  the  dorsum  and  rarely  on 
the  plantar  surface.  They  generally  become  very  large  and  involve  the  entire 
sole  before  they  rupture;  or  they  may  work  their  way  through  and  rupture 
on  the  dorsum.     This  is  due  to  the  dense  fascia  on  the  sole  of  the  foot. 

In  tuberculosis  of  the  metatarsals  and  phalanges  the  disease  is  usually 
multiple.  In  adults  there  is  a  tendency  for  the  involvement  to  take  place 
at  the  metatarsophalangeal  joints. 

Treatment. — On  account  of  the  arrangement  of  the  structures  involved 
in  tuberculous  disease  of  the  tarsus  there  is  a  marked  tendency  for  rapid  ex- 
tension. Operative  treatment  is  always  advisable.  In  disease  of  the  cal- 
caneum  foci  should  be  removed  by  chiseling,  and  if  the  destruction  of  bone 
is  extensive  the  osteoplastic  resection  of  v.  Mikulicz  is  advisable. 

Disease  of  the  astragalus  usually  necessitates  astragalectomy  and  at  times 
resection  of  the  joint.  This  may  be  performed  by  Kocher's,  Lauenstein's, 
or  Konig's  methods. 

In  disease  of  the  tarsal  bones  if  the  process  has  not  extended,  resection 
of  the  bone  involved  may  check  the  disease.  This  should  be  the  rule  in  children. 
Anterior  tarsectomy  should,  however,  be  performed  in  adults  if  the  disease 
is  at  all  extensive,  as  the  growth  of  the  bones  would  be  insuflficient  to  prevent 
deformities  by  simple  resection. 

Involvement  of  the  metatarsals  and  phalanges  calls  for  removal  of  the 
metatarsals  and  amputation  of  the  toes,  as  the  resulting  cicatrices  in  conserva- 
tive treatment  of  the  latter  often  prove  troublesome. 

In  all  cases  when  the  disease  is  very  extensive  and  there  are  no  contra- 
indications to  conservative  treatment  the  latter  may  be  tried  for  a  time,  especially 
in  childhood.  In  adults,  however,  the  result  obtained  is  so  poor  in  most  cases 
that  amputation  is  preferable  not  only  in  the  time  gained,  but  also  in  the  use- 
fulness of  the  stump,  to  which  an  artificial  foot  may  be  attached.  When  any 
contraindications  are  present  amputation  should  be  performed,  as  the  loss 
of  the  foot  is  more  than  amply  compensated  by  the  shortened  convalescence, 
the  usefulness  of  the  part,  and  the  slight  risk  incurred  by  operative  interference. 


CHAPTER  IX. 
NON-TUBERCULOUS  DISEASES  OF  THE  ANKLE-JOINT. 

Acute  Sprain  of  the  Ankle-joint. 

xAn  acute  sprain  is  the  term  used  to  denote  the  condition  produced  by 
traumatism  which  ordinarily  would  result  in  fracture  or  dislocation  of  the 
ankle-joint.  The  force,  while  it  is  probably  not  sufficient  or  not  applied  in 
the  right  direction  to  cause  fracture  or  dislocation,  yet  causes  tears  of  the  synovial 
membrane  or  extensive  laceration  of  the  ligaments,  especially  the  lateral.  In- 
version and  eversion  at  the  ankle-joint  are  not  possible  except  in  extreme  ex- 
tension, and  then  only  to  a  very  slight  degree;  when,  however,  the  weight 
of  the  body  is  thrown  upon  the  foot  while  it  is  in  a  position  of  inversion 
or  eversion,  which  movements  take  place  at  the  mediotarsal  joint,  fracture 
of  either  malleoli,  dislocation,  or  sprain  occurs.  Sprains  by  inversion  are 
produced  when  the  foot  is  inverted,  supinated,  and  extended.  The  force 
therefore  falls  upon  the  external  lateral  ligaments.  Sprains  by  eversion  are 
produced  when  the  foot  is  everted,  pronated,  and  flexed.  While  a  sprain 
occurs  in  this  manner,  it  is  more  frequent,  however,  for  a  fracture  of  the  internal 
malleolus  result  on  account  of  strength  of  the  internal  lateral  ligaments.  Sprains 
by  inversion  are  very  often  accompanied  by  some  tears  of  the  ligaments  betw^een 
the  calcaneum  and  cuboid  and  scaphoid  and  cuneiform  bones. 

Symptoms. — Immediately  following  a  twist  upon  the  ankle  there  is 
severe  pain,  tenderness  on  pressure,  and  rapid  swelling  takes  place.  The 
swelling  is  below  and  anterior  to  the  external  malleolus  in  sprains  by  eversion 
and  in  a  similar  relation  to  the  internal  malleolus  in  sprains  by  inversion.  In- 
volvement of  the  tarsal  joint  is  recognized  by  the  localized  swelling,  tenderness, 
and  pain.  In  severe  cases  the  swelling  may  involve  the  entire  circumference 
of  the  foot,  ankle,  and  lower  half  of  the  leg.  Severe  sprains  are  characterized 
by  ecchymosis,  which  may  be  very  extensive  and  usually  appears  in  twenty- 
four  hours. 

Diagnosis. — This  rests  upon  the  history  of  injury,  swelling,  pains,  tender- 
ness, ecchymosis,  and  absence  of  faulty  position  and  crepitus.  The  condition 
is  to  be  differentiated  from  fracture  of  the  malleoli  by  the  position  of  the  initial 


NON-TUBERCULOUS  DISEASES  OF  THE  ANKLE-JOINT.  473 

swelling,  which  is  always  confined  to  the  limits  of  the  synovial  membrane, 
whereas  in  fracture  the  primary  swelling,  being  due  to  an  exudation  of  serum 
and  blood  at  the  seat  of  fracture,  is  usually  situated  \  inch  to  i|  inches  above 
the  tips  of  the  malleoli.  In  sprain  there  are  absence  of  crepitus,  abnormal 
mobility,  and  deformity,  and  the  tenderness  is  generally  at  the  tips  of  the 
malleoli.  After  twelve  to  twenty-four  hours  there  may  be  considerable  diffi- 
culty of  diagnosis,  which  will  be  overcome  by  :x:-ray  examination. 

Treatment. — In  reference  to  treatment  sprains  may  be  classified  as  slight 
and  severe.  Slight  sprains,  if  seen  immediately  before  any  infiltration  of  the 
tissues  has  taken  place,  should  be  treated  by  compression,  rest,  and  fixation. 
Compression  may  be  obtained  by  an  elastic  bandage  extending  from  the  toes 
to  the  mid-leg.  The  patient  should  be  put  to  bed  and  the  foot  supported  by 
sand-bags.  At  the  end  of  twenty-four  hours  massage  may  be  used  and  the 
ankle  supported  by  Cotterell's  adhesive  plaster  dressing  or  a  light  plaster- 
of-Paris  bandage  extending  from  the  toes  to  just  below  the  knee.  The  adhesive 
plaster  dressing  allows  moderate  use  with  fixation.  It  can  be  changed  every 
three  or  four  days,  and  at  the  end  of  ten  days  may  be  replaced  by  a  flannel 
bandage.  The  plaster-of-Paris  bandage  may  be  split  down  either  side  and 
removed  daily  for  massage.  It  should  be  discarded  in  ten  days  and  a  flannel 
bandage  applied.  In  severe  cases  the  joint  should  be  placed  at  absolute  rest 
for  two  to  three  weeks.  Fixation  is  best  accomplished  by  keeping  the  patient 
in  bed  with  the  foot  immobilized  in  a  fracture  box  or  until  the  swelling  has 
subsided,  and  then  a  plaster-of-Paris  bandage  should  be  applied  from  the 
toes  to  just  below  the  knee  and  the  patient  allowed  the  use  of  crutches.  At 
the  end  of  two  weeks  passive  motion  which  will  not  tend  to  stretch  the  involved 
ligaments  may  be  given  in  addition  to  the  massage,  and  at  the  end  of  three 
weeks  the  plaster  splint  may  be  discarded,  a  flannel  bandage  applied,  the  patient 
should  be  encouraged  to  use  the  leg,  and  in  addition  to  massage  and  passive 
and  active  motion,  baking  of  the  joint  with  hot  air  may  be  used  every  other 
day.  Such  prolonged  treatment  is  advisable  in  severe  cases  of  sprain  to  allow 
complete  repair  of  the  torn  ligaments  and  to  prevent  the  general  weakness 
and  recurrence  of  the  condition  which  follow  hasty  and  rapid  treatment. 

Chronic  Sprain  of  the  Ankle-joint. 

Chronic  sprains  of  the  ankle-joint  may  be  due  to  a  weakness  or  stretching 
of  the  ligaments  as  a  result  of  an  acute  sprain.  Many  cases  are  due  to  a  lack 
of  repair  at  the  point  of  rupture  in  acute  cases,  so  that  there  results  marked 


474  ORTHOPEDIC  SURGERY. 

increase  of  the  normal  lateral  motion  at  the  joint  and  considerable  instability  of 
the  foot.  It  is  s)Tionymous  with  traumatic  flat-foot,  Avhich  results  from  an  acute 
sprain  of  the  mediotarsal  or  calcaneo-astragaloid  joint.  It  is  sometimes  seen 
following  prolonged  fixation  in  splints  or  from  disuse.  At  times  the  eft'usion 
of  an  acute  attack  may  not  be  entirely  absorbed,  or  may  result  in  adhesions 
which  in  time  limit  flexion  and  extension  and  cause  a  certain  amount  of  muscular 
fixation.  Through  fear  of  injury  some  patients  refuse  to  use  the  joint  after  an 
acute  attack,  and  as  a  result  the  foot  assumes  a  faulty  position,  atrophy  of  muscles 
takes  place,  adhesions  occur,  the  soft  parts  about  the  ankle  remain  congested 
and  edematous,  so  that  the  acute  condition  is  verj^  liable  to  become  chronic. 

Symptoms. — The  patient  complains  of  a  weak,  unstable  joint,  which 
is  continually  "turning  under  him"  in  unguarded  moments.  The  soft  parts 
about  the  ankle  are  swollen,  there  may  be  slight  tenderness  on  pressure,  normal 
flexion  and  extension  may  be  limited  on  account  of  adhesions,  while  lateral 
movements  are  increased.  The  s}Tiovial  cavity  is  distended  and  marked 
fluctuation  present.  The  foot  is  generally  held  in  a  position  of  equino-valgus. 
Involvement  of  the  mediotarsal  or  calcaneo-astragaloid  joints  causes  marked 
tenderness  along  the  inner  and  plantar  surfaces  of  the  foot  and  back  of  the 
leg.     This  is  accompanied  by  flattening  of  the  sole  of  the  foot. 

Treatment. — This  consists  in  restoring  the  normal  function  of  the  joint 
as  much  as  possible.  Massage,  baking  with  hot  air,  active  and  passive  motion, 
should  be  given  in  all  cases  to  restore  muscular  tone  and  break  up  any  adhesions 
that  may  be  present.  If  the  foot  is  held  in  an  abnormal  position  and  the  normal 
joint  motions  markedly  restricted  they  should  be  corrected  gradually  or  in 
some  cases  under  anesthesia.  If  the  deformed  position  is  marked,  after  correc- 
tion a  plaster-of-Paris  bandage  should  be  applied  to  hold  the  foot  for  a  time 
in  an  exaggerated  opposite  position.  After  removal  of  the  plaster  bandage 
recurrence  of  deformity  may  be  prevented  by  a  suitable  walking  brace.  Trau- 
matic flat-foot  should  be  treated  by  appropriate  foot  plates,  massage,  and 
active  and  passive  movements  of  the  foot.  In  all  cases  gradual  use  of  the 
foot  with  suitable  protection,   as  an  ankle  support,   should  be  encouraged. 

Tenosynovitis. 

The  sheaths  and  their  inclosed  tendons  about  the  ankle-joint  may  be 
subject  to  acute,  chronic,  and  tuberculous  inflammation.  As  an  acute  afl'ection 
it  may  accompany  sprains  of  the  ankle  or  may  be  due  to  excessive  use  of  a 
group  or  groups  of  muscles  connected  with  the  tendons.     This  is  sometimes  met 


NON-TUBERCULOUS  DISEASES  OF  THE  ANKLE-JOINT.  -175 

in  skating  or  any  similar  exercise.  It  may  be  due  to  rheumatic  diatliesis  or 
an  acute  infection.  Chronic  tenosynovitis  is  met  as  a  result  of  recurrent  acute 
attacks,  rheumatism,  gonorrhea,  and  infectious  diseases.  Tuberculous  teno- 
synovitis sometimes  occurs  apparently  without  any  involvement  of  other  struc- 
tures. 

Pathology. — In  the  acute  stage  the  sheath  is  congested  and  distended 
with  serous  fluid,  containing  a  moderate  amount  of  fibrin,  which  later  produces 
adhesions  between  the  tendon  and  its  sheath,  the  rupture  of  which  produces 
crepitation  characteristic  of  the  affection.  In  the  chronic  varieties  there  is 
thickening  of  the  sheath,  a  variable  amount  of  fluid,  adhesions,  and  in  the 
tuberculous  variety  rice  bodies. 

Symptoms. — The  symptoms  of  acute  tenosynovitis  are  pain,  on  muscular 
action,  tenderness,  limited  to  the  involved  areas,  on  pressure,  swelling,  and 
crepitation  on  active  motion.  In  the  chronic  form  the  foot  assumes  various 
deformed  positions,  there  is  moderate  muscular  atrophy,  and  there  are  swelling, 
localized  thickening,  and  fluctuation  over  the  involved  sheath.  Tuberculous 
tenos)^novitis  is  accompanied  by  very  little  pain,  no  limitation  of  motion,  at 
times  there  may  be  localized  crepitus,  and  the  presence  of  rice  bodies  can  often 
be  felt. 

Treatment. — In  acute  tenosynovitis  the  treatment  consists  in  compression; 
counterirritants,  as  tincture  of  iodin,  cantharidal  collodion,  or  the  cautery; 
and  fixation  by  means  of  a  Cotterell  adhesive  plaster  dressing  or  a  plaster- 
of-Paris  bandage  extending  from  the  toes  to  the  knee.  The  splint  should 
completely  prevent  all  muscular  action  in  the  leg.  This  treatment  should 
be  supplemented  by  large  doses  of  sodium  salicylate,  as  these  cases  improve 
very  rapidly  under  the  salicylates.  After  immobilization  from  five  to  six  days, 
massage,  baking  with  hot  air,  and  passive  motion  should  be  instituted,  and 
support  given  with  a  flannel  bandage.  Chronic  tenos}'novitis  may  yield  to 
the  above  treatment,  but  in  persistent  cases  it  may  be  necessary  to  remove 
the  affected  sheath.  Tuberculous  tenosynovitis  calls  for  complete  removal 
of  the  sheath  or  sheaths  affected. 


CHAPTER  X. 
TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT. 

Of  all  the  major  joints,  the  shoulder  is  among  the  least  frequently  affected 
by  tuberculous  disease.  This  may  be  accounted  for,  possibly,  by  the  part 
traumatism  plays  as  an  exciting  cause  of  this  condition;  yet  aside  from  this, 
it  is  difficult  to  say  anatomically  why  the  head  of  the  humerus  should  be  affected 
so  little  when  compared  with  the  head  of  the  femur.  Thus  in  5680  cases  of 
orthopedic  affections  treated  in  the  Orthopedic  Department  of  the  Hospital 
of  the  University  of  Pennsylvania  there  were  only  7  cases  of  this  affection. 

Statistics. — Oilier  states  that  Crocq  saw  one  case  in  140.  Billroth  observed 
28  cases  of  tuberculous  shoulder-joint  disease  in  1996  cases.  Townsend  states 
that  in  3244  cases  of  bone  and  joint  tuberculosis  observed  at  the  Hospital  for 
ruptured  and  crippled  from  1899  to  1893  the  shoulder-joint  was  involved  in  21 
instances.  Whitman  records  1833  consecutive  cases  of  joint  disease — excluding 
Pott's  disease — treated  in  the  out-patient  department  of  the  same  hospital 
during  five  years,  in  which  the  shoulder-joint  was  involved  in  38  instances. 

Age. — Townsend,  in  his  21  cases,  observed  that  the  average  age  at  the 
time  of  onset  was  twelve  years;  the  youngest  patient  was  three  and  a 
quarter  years,  the  oldest  thirty-five  years.  Whitman's  statistics  of  62  cases 
showed  the  average  age  to  be  a  little  higher  than  Townsend's;  the  youngest 
was  one  year,  the  oldest  fifty-six  years. 

Of  the  twenty-one  cases  reported  by  Townsend,  in  five  there  existed 
tuberculosis  of  other  joints;  one  had  Pott's  disease;  two  had  disease  of  the 
hip  and  two  knee-joint  disease;  but  in  these  five  cases  the  disease  of  the  shoulder 
was  secondary  to  that  of  the  other  joints. 

Pathology. — The  pathologic  change'  which  takes  place  here  is  similar 
to  that  of  other  joints.  The  primary  focus  is  generally  in  the  head  of 
the  humerus. 

The  most  common  form  of  tuberculous  shoulder-joint  disease  is  caries 
sicca,  consisting  of  a  gradual  destruction  of  the  head  and  the  formation  of 
granulation  tissue.  This  form  may  be  so  extensive  in  some  cases  that  not 
only  is  the  head  destroyed  but  part  of  the  shaft  may  be  involved.     This  usually 


TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  477 

occurs  without  the  formation  of  abscesses.  When  the  tuberculous  process 
extends  into  the  medullary  cavity  of  the  shaft,  the  process  is  termed  caries 
carnosa.  Mondan  and  Audry  record  abscess  formation  in  2)2,  of  the  40  cases 
of  tuberculosis  of  the  shoulder-joint.  When  this  occurs,  numerous  sinuses  are 
formed  by  the  joint  contents  finding  their  way  along  the  long  tendon  of  the 
biceps,  to  open  on  the  surface  of  the  arm,  below  the  anterior  fold  of  the  axilla, 
or  perforating  the  joint  capsule,  escape  beneath  the  deltoid  muscle,  to  present 
themselves  in  the  inter-muscular  septum  between  the  deltoid  and  the  pec- 
toralis  major  in  front  of  or  between  the  shoulder  and  the  scapula  behind. 

Symptoms. — In  most  cases  without  any  history  of  injury  being  present 
there  is  noticed  on  rising  in  the  morning  slight  pain  about  the  shoulder,  which 
may  be  referred  down  the  arm,  is  considered  to  be  of  neuralgic  character,  and 
disappears  after  several  hours.  This  S3anptom  returns,  with  increasing  severity 
daily;  the  localized  and  referred  pains  increase  in  amount  and  are  greatly 
aggravated  by  motions  which  are  caused  irrespective  of  the  scapula.  Soon 
there  appears  local  tenderness,  which  is  particularly  marked  in  the  axilla  and 
posteriorly.  Swelling  is  an  early  S}nnptom  and  is  shown  by  increased  cir- 
cumference of  the  shoulder.  This  swelling  shortly  gives  way  to  flattening 
of  the  shoulder,  which  is  caused  by  atrophy  of  the  deltoid  muscle  in  the  early 
stages  and  in  the  caries  sicca  variety  by  atrophy  of  the  head  of  the  humerus. 
Limitation  of  motion  is  present  from  the  beginning,  and  while  the  patient 
may  use  the  shoulder  to  a  moderate  degree,  he  is  able  to  do  so  on  account  of  the 
normal  mobility  of  the  scapula.  Muscular  spasm  is  an  early  symptom,  and 
when  atrophy  of  the  head  occurs,  the  proximal  end  of  the  shaft  may  be  dravra 
up  and  inward  so  as  to  produce  prominence  of  the  acromion  process  of  the 
scapula,  and  in  some  cases  the  deformity  will  be  so  great  as  to  resemble  a 
subcoracoid  dislocation.  When  abscesses  form,  there  are  swelling  of  the  soft 
parts  about  the  shoulder,  increased  local  and  general  temperature,  and  rigors, 
and  burrowing  of  pus  takes  place. 

Diagnosis. — This  affection  must  be  distinguished  from  primary  bursitis 
and  rheumatoid  arthritis  limited  to  the  shoulder-joint.  Inflammation  of 
the  bursae  beneath  the  tendons  of  the  subscapularis  and  infraspinatus  muscles 
is  usually  secondary  to  shoulder-joint  disease,  but  when  primary,  pain  will  be 
elicited  by  drawing  the  arm  away  from  the  scapula  and  rotating  it  from  side 
to  side,  and  the  essential  symptoms  of  joint  disease  so  often  described  wfll 
be  absent.  In  primary  bursitis  of  the  sac  beneath  the  deltoid  muscle  all  the 
movements  of  the  arm  will  be  painful  with  the  arm  hanging  by  the  side.     Rheu- 


47S  ORTHOPEDIC  SURGERY. 

matoid  arthritis  is  a  disease  of  advanced  life,  the  head  of  the  humerus  is  elevated 
and  advanced  forward,  crepitation  is  present  in  the  joint,  without  suppuration, 
rigors,  fever,  sweating,  or  other  symptoms  of  tuberculous  joint  lesion. 

Prognosis. — Unless  the  disease  be  early  arrested,  the  destruction  of  the 
head  of  the  humerus  will  be  excessive  and  atrophy  of  the  muscles  great.  The 
prognosis  is  not  so  favorable  as  in  other  large  joints.  This  is  due  partly  to  the 
fact  that  the  average  age  is  greater,  many  cases  occurring  in  adults,  and  that 
a  large  percentage  are  complicated  by  pulmonary  tuberculosis.  The  advent 
of  suppuration  increases  the  gravity  of  the  prognosis.  Under  favorable  circum- 
stances caries  sicca  tends  to  spontaneous  cure,  by  ankylosis,  in  from  two  to  three 
years.     The  results  of  conservative  treatment  are  excellent. 

Treatment, — The  indications  for  treatment  of  tuberculous  shoulder- 
joint  disease  are  the  same  as  those  of  other  joints,  namely,  rest,  fixation,  and 
protection.  The  elbow  should  be  flexed,  the  forearm  placed  in  a  sling,  and 
the  arm  held  to  the  side,  by  some  dressing,  as  adhesive  plaster.  The  weight 
of  the  elbow  will  serve  as  traction.  In  some  cases  it  may  be  necessary  to  im- 
mobilize the  entire  upper  extremity  by  means  of  a  plaster-of-Paris  bandage. 
If  muscular  spasm  and  pain  are  extreme,  they  may  be  relieved  by  supporting 
the  arm  at  a  right  angle  to  the  body,  as  advised  by  Monks.  This  may  be  done 
by  means  of  a  plaster-of-Paris  bandage  or  a  wire  splint  made  so  as  to  hold 
the  arm  away  from  the  chest.  This  position  materially  relaxes  the  deltoid 
muscle  and  other  joint  structures,  relieves  the  tension  on  the  nerves,  and  aids 
by  means  of  the  weight  of  the  arm  in  separating  the  articular  surfaces. 

A  large  majority  of  cases  will  recover  under  conservative  treatment. 
This  is  partly  due  to  the  fact  that  the  joint  is  well  protected  from  injury 
and  can  readily  be  put  at  rest.  This  is  possible  because  a  considerable  change 
of  movement  of  the  shoulder  may  take  place  without  the  head  of  the  humerus 
moving  in  the  glenoid  cavity,  on  account  of  the  free  mobility  of  the  scapula. 

When  abscesses  form  about  the  shoulder,  they  may  be  aspirated  and 
injected  with  iodoform  emulsion  or  irrigated  with  a  carbolic  acid  solution 
(3  to  5  per  cent.).  If  mixed  infection  is  present,  the  suppurating  area  should 
be  incised  and  drained.  In  children  arthrectomy  may  be  necessary.  This 
should  be  preferable  to  resection,  as  very  often  the  tuberculous  area  may 
be  removed  without  destroying  the  entire  head  of  the  bone.  In  adults 
when  conservative  treatment  has  failed  and  the  general  condition  is  bad, 
resection  offers  the  best  functional  results.  This  operation  consists  in  mak- 
ing   an    anterior    longitudinal    incision    down    to    the    periosteum,    dividing 


TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  479 

the  latter,  and  separating  it  from  the  bone  as  much  as  possible  by  rotation 
of  the  arm;  the  head  of  the  bone  and  as  much  of  the  shaft  as  is  diseased  can 
be  removed  by  a  chisel  or  saw,  or  the  head  may  be  brought  out  through  the 
wound  and  excised.  All  tuberculous  tissue  of  the  glenoid  cavity  and  capsule 
of  the  joint  should  be  thoroughly  removed.  The  wound  may  be  closed  in  the 
hope  of  obtaining  primary  union,  or  a  small  gauze  drain  may  be  inserted.  Posi- 
tion and  fixation  should  be  obtained  by  proper  padding  and  the  application 
of  a  plaster-of-Paris  bandage.  At  the  end  of  three  to  four  weeks  passive  motion 
and  massage  should  be  instituted.  This,  however,  should  be  moderate,  lest 
a  flail  joint  be  produced,  ankylosis  being  preferable. 

Amputation  is  advised  when  marked  cachexia  is  present,  when  suppu- 
ration is  very  extensive,  and  in  those  cases  in  which,  on  account  of  the  marked 
destruction  of  the  shaft, — as  in  caries  carnosa, — the  resulting  arm  would  be 
entirely  useless. 

Injections  of  iodoform-glycerin  (lo  per  cent.)  and  passive  congestion  by 
Bier's  method  as  supplementary  to  mechanical  treatment  have  been  found 
of  value.  Tincture  of  iodin,  cantharides,  and  the  Paquelin  cautery  may  be 
used  locally  in  the  early  stages.  The  general  health  should  be  improved  by 
cod-liver  oil,   hypophosphites,    iron,    quinin,   malt  liquors,    and   other  tonics. 

During  convalescence  gradual  passive  motion  combined  with-  massage 
and  baking  with  hot  air  will  be  of  benefit  in  reducing  the  amount  of  fixation 
due  to  adhesions.  If  the  limitation  of  motion  is  very  marked,  it  may  be  forcibly 
overcome  by  manipulations  under  anesthesia.  Passive  motion,  however, 
should  not  be  attempted  until  all  muscular  spasm  has  ceased. 


CHAPTER  XL 
NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT. 

Subdeltoid  Bursitis. 

Inflammatory  conditions  of  the  subdeltoid  bursa  may  be  acute,  chronic^ 
tuberculous,  or  suppurative  in  character.  This  bursa  is  situated  between 
the  deltoid  and  supraspinatus  and  infraspinatus  muscles  and  the  coraco- 
acromial  ligament. 

Acute  subdeltoid  bursitis  is  usually  due  to  injury  and  consists  of  an 
acute  serous  effusion  which  at  times  may  contain  a  varying  amount  of  blood. 
It  is  sometimes  seen  in  connection  with  inflammatory  conditions  of  the  sheath 
of  the  biceps  tendon. 

Chronic  subdeltoid  bursitis,  first  described  by  Duplay  in  1872  under 
the  name  of  "periarthritis  humeroscapularis,"  is  due  to  direct  or  indirect  trau- 
matism or  occurs  as  a  result  of  gonococcus  infection  or  rheumatism. 

Tuberculous  subdeltoid  bursitis  may  be  primary  or  may  be  due  to 
a  secondary  involvement  by  extension  from  the  shoulder-joint.  Its  most 
striking  characteristic  is  the  presence  in  the  deltoid  region  of  a  swelling  which 
may  reach  the  size  of  a  grape-fruit  and  simulate  malignant  or  benign  growths. 

Suppurative  subdeltoid  bursitis  is  usually  seen  following  a  pyogenic 
infection  of  the  shoulder-joint  or  an  acute  suppurative  epiphysitis  or  osteo- 
myelitis. 

Symptoms. — The  most  marked  symptom  is  a  fluctuating  swelling  limited 
to  the  deltoid  region.  In  the  acute,  chronic,  and  tuberculous  varieties  pain 
and  tenderness  on  pressure  are  very  slight.  In  the  suppurative  variety  there,  are 
pain,  tenderness,  redness  of  the  overlying  skin,  and  subjacent  edema  present. 
In  the  tuberculous  form  the  swelling  may  become  very  large,  so  as  to  simulate 
malignant  or  benign  growths,  as  sarcomata  or  lipomata.  Movements  of  the 
arm  which  cause  the  swelling  to  become  very  tense  are  painful,  and  there  may 
be  referred  pain  down  the  arm  to  the  fingers. 

Diagnosis. — This  rests  upon  the  history,  the  localization  of  the  swelling 
to  the  deltoid  region,  in  most  cases  the  absence  of  involvement  of  the  shoulder- 
joint,  and  in  the  suppurative  variety  the  presence  of  a  primary  focus  of  infection. 


NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  481 

The  condition  should  be  carefully  differentiated  from  tenosynovitis  of 
the  biceps  tendon,  from  shoulder-joint  affections,  and  from  malignant  and 
benign  growths. 

Treatment. — In  the  acute  and  chronic  forms  this  consists  in  putting 
the  part  at  rest,  the  use  of  counterirritants,  and  the  use  of  massage  and  elec- 
tricity when  the  acute  S3Tnptoms  have  subsided.  The  tuberculous  variety 
is  treated  upon  the  same  general  principles  as  tuberculous  disease  of  other 
bursas.     The  suppurative  variety  requires  incision  and  drainage. 

Acromial  Bursitis. 

Inflammation  of  the  acromial  bursa  usually  is  due  to  an  occupation  neces- 
sitating the  carrying  of  heavy  burdens  upon  the  shoulder,  as  seen  in  hod-carriers. 
Enlargement  of  this  bursa  rarely  gives  rise  to  subjective  symptoms.  It  is 
characterized  by  the  presence  of  a  round,  fluctuating,  non-tender  swelling 
over  the  acromion  process  of  the  scapula.  Motion  at  the  shoulder- joint  is 
not  affected  by  its  presence.  If  it  gives  rise  to  subjective  symptoms,  or  if  it 
undergoes  suppuration,  it  may  be  dissected  out  from  the  surrounding  structures 
or  incised,  and  its  cavity  then  thoroughly  cureted  and  drained.  Similar  in- 
flammatory changes  may  take  place  in  the  subscapular,  subcoracoid,  and 
subserrate  bursce. 

Loose  Shoulder-joint. 

By  the  term  loose  shoulder-joint  is  meant  the  lax  condition  found  as  a 
result  of  iniiammatory  and  destructive  processes  or  paralysis.  It  is  seen  when 
there  has  been  considerable  destruction  of  the  head  of  the  bone  following  gun- 
shot wounds,  fractures,  and  resection.  It  may  result  from  inflammatory  pro- 
cesses causing  entire  disorganization  of  the  joint,  as  purulent  arthritis.  It 
may  accompany  Charcot's  disease  and  syringomyelia.  It  may  follow  injuries 
to  the  brachial  plexus,  circumflex  and  subscapular  nerves.  It  may  follow 
injuries  received  at  birth,  as  epiphyseal  separations  and  fractures,  or  may 
be  due  to  infantile  paralysis. 

Symptoms, — The  symptoms  of  loose  shoulder- joint  are  essentially  those 
of  a  relaxed  joint.  This  laxity  varies  to  a  marked  degree  according  to  the 
cause.  It  may  be  very  little  more  than  normal  or  in  some  cases  may  be  so 
great  that  there  is  a  well-marked  space  between  the  acromion  process  of  the 
scapula  and  the  head  of  the  humerus.  The  acromion  process  is  very  prominent, 
being  due  to  the  atrophy  of  the  surrounding  muscles,  especially  the  deltoid. 


482  ORTHOPEDIC  SURGERY. 

and  the  inability  of  the  head  of  the  humerus  to  assist  in  forming  the  normal 
contour  of  the  shoulder.  The  arm  in  some  cases  may  be  very  useful  up  to 
a  certain  point  in  abduction  when  the  dislocation  occurs,  or  in  some  cases  it 
may  hang  at  the  side,  rotated  inward,  with  the  hand  pronated,  and  be  perfectly 
powerless  as  far  as  motions  at  the  shoulder  are  concerned.  In  some  cases 
the  best  motion  that  can  be  obtained  consists  in  a  swinging  movement  of  the 
entire  arm.  The  head  of  the  humerus  in  some  cases  is  in  fairly  good  apposition 
to  the  glenoid  cavity,  in  others  it  may  be  separated  from  it  by  several  inches. 
By  passive  movement  the  head  may  readily  be  displaced  in  all  directions. 

Prognosis. — The  prognosis  is  exceedingly  poor.  The  condition,  even 
with  operation,  becomes  progressively  worse,  so  that  after  a  time  the  entire 
arm  is  useless. 

Treatment. — The  treatment  of  this  condition  may  be  mechanical  or 
operative.  The  mechanical  treatment  consists  in  an  appropriate  apparatus 
which  limits  abduction  and  elevation  and  at  the  same  time  holds  the  head 
of  the  humerus  in  the  best  possible  position.  All  these  apparatus  consist  of 
an  arm-piece  made  of  cloth,  leather,  or  some  similar  material,  strengthened 
with  steel  bands.  The  arm-piece  is  continued  over  the  shoulder  antero-pos- 
teriorly  and  to  the  base  of  the  neck.  The  shoulder  portion  is  continued  down 
the  chest  and  passes  completely  around  it  to  the  opposite  axilla.  A  steel  bar 
runs  from  the  base  of  the  neck  over  the  joint  of  the  shoulder  and  down  to  the 
external  surface  of  the  arm.  Opposite  the  shoulder  there  is  a  joint  which 
allows  antero-posterior  motion  but  prevents  abduction  and  elevation.  Among 
the  most  trustworthy  apparatus  are  those  recommended  by  Hoffa,  Billroth, 
and  Collin. 

Attempts  may  be  made  to  secure  ankylosis  by  removing  the  articular 
cartilages  and  in  some  cases  a  portion  of  the  epiphysis.  This  has  been  per- 
formed by  Wolff  and  Karewski.  The  head  of  the  humerus  may  be  sutured 
to  the  glenoid  cavity  by  means  of  silver  wire.  Other  operations  consist  in 
the  transplantation  of  muscles,  as  was  done  by  Hoffa,  who  secured  a  good 
result  by  splitting  up  a  portion  of  the  insertion  of  the  trapezius  and  implanting 
it  into  the  deltoid  muscle. 

Recurrent  Dislocation  of  the  Shoulder. 

By  recurrent  dislocation  of  the  shoulder  is  meant  a  reproduction  of  a 
dislocation  that  is  made  possible  by  a  structural  change  in  the  articulating 
surfaces  or  capsule  of  the  joint,  so  that  a  force  or  movement  which  would 


NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  483 

not  cause  the  condition  to  occur  in  a  normal  joint  is  followed  by  the  characteristic 
deformity.  This  is  frequently  seen  in  cases  which  have  been  treated  an  in- 
sufficient length  of  time  to  allow  for  natural  repair. 

The  conditions  present  to  cause  this  recurrence  are:  (i)  A  very  large 
tear  in  the  capsule.  This  is  usually  situated  in  the  anterior  or  internal  aspect. 
(2)  A  lax  condition  of  the  entire  capsule  may  be  present,  or,  instead  of  the 
insertion  of  the  capsule  at  the  inner  margin  of  the  joint,  there  may  be  free  com- 
munication between  the  joint  and  the  subscapular  bursa.  (3)  There  may  be 
a  partial  fracture  of  the  head  of  the  humerus,  so  that  a  resulting  osteochrondritis 
dissecans  takes  place,  causing  a  groove  on  the  posterior  surface  of  the  head 
of  the  humerus.  (4)  A  fracture  may  be  present  on  the  inner  edge  of  the 
glenoid  cavity,  thus  reducing  the  depth  of  the  cavity.  (5)  Joessel  considered 
that  in  some  instances  the  rotators  or  the  great  tuberosity  were  torn  off,  with 
the  result  that  there  was  a  marked  lessening  of  the  concentric  stability  of  the 
articular  surfaces  during  motion.  (6)  Burrell  and  Lovett  consider  that  the 
atrophy  and  fiabbiness  of  certain  of  the  muscles  of  the  affected  side  had  con- 
siderable to  do  in  the  causation  of  the  lesion.  (7)  Some  cases  are  due  undoubt- 
edly to  syringomyelia  and  Charcot's  disease. 

Symptoms. — Following  the  primary  dislocation  there  may  be  a  period 
of  weeks  or  months  without  a  recurrence  taking  place,  until  suddenly  while 
the  arm  is  in  a  certain  position  dislocation  recurs.  This  may  follow  very  slight 
exertion,  and  in  some  cases  there  is  absolutely  no  trauma.  The  condition 
seems  to  occur  simply  by  muscular  action  when  the  arm  is  held  in  certain 
positions  favorable  for  the  production  of  the  dislocation.  The  displacement 
may  be  anterior  or  posterior.  The  greater  majority  are  posterior.  The  dis- 
location may  recur  several  times,  and  not  again  for  a  long  period,  or  it  may 
occur  many  times.  As  a  result  of  the  condition  there  is  atrophy  of  muscles 
about  the  shoulder.  Whether  this  is  due  to  disuse  or  whether  it  is  the  cause 
of  the  condition  has  not  been  decided.  There  usually  results  moderate  limi- 
tation of  motion,  which  is  not  due  to  muscular  action,  but  in  all  probability 
to  changes  in  the  joint  structures,  and  to  the  formation  of  fringes,  loose  bodies, 
and  exostoses. 

Prognosis. — Without  treatment  it  is  rare  for  a  complete  cure  to  take 
place.  With  proper  apparatus  to  limit  abduction  and  elevation  of  the  arm, 
recurrences  can  be  prevented.  The  best  results  have  been  obtained  by  opera- 
tion. 

Treatment. — This  may  be  divided  into  mechanical  and  operative.     Re- 


484  ORTHOPEDIC  SURGERY. 

duction  is  usually  accomplished  with  ease.  When  cases  are  first  seen  and 
there  have  been  only  a  few  recurrences,  the  lesion  present  is  probably  a  loose 
capsule.  This  should  be  treated  by  massage,  electricity,  and  passive  motion. 
Movements — chiefly  abduction  and  elevation — which  generally  cause  the 
recurrence  are  to  be  prohibited. 

The  best  apparatus  is  the  one  already  described  under  Loose  Shoulder- 
joint.  In  conjunction  with  the  apparatus  massage,  electricity,  and  passive 
motion  should  be  given.  Attempts  at  cure  have  been  made  from  time  to  time 
by  the  injection  into  the  joint  of  iodoform  emulsion  and  tincture  of  iodin,  and 
while  in  several  instances  good  results  have  been  obtained,  the  utility  of  this 
method  is  questionable.  In  general,  these  latter  methods  have  fallen  into 
disuse,  and  it  is  now  considered  that  operative  treatment  is  the  one  most  often 
followed  by  good  results. 

All  the  operations  in  vogue  aim  to  restore  the  stability  of  the  head  of  the 
humerus  by  narrowing  of  the  capsule  of  the  joint.  This  may  be  performed 
in  several  ways,  differing  from  each  other  only  in  the  method  of  treating  the 
capsule.  The  arm  being  held  in  slight  abduction,  a  vertical  incision  about 
4  inches  long  is  made  on  the  anterior  surface  of  the  arm  from  the  coracoid 
process  to  the  insertion  of  the  pectoralis  major  muscle.  The  latter  is  separated 
from  the  deltoid,  exposing  the  subscapularis  muscle.  The  subscapularis  and 
the  upper  half  of  the  insertion  of  the  pectoralis  major  muscles  are  divided,  ex- 
posing the  capsule  of  the  joint.  It  may  be  narrowed  by  taking  out  a  triangular 
portion  of  the  anterior  wall  of  the  capsule  and  suturing  the  edges  with  chromi- 
cized  catgut;  by  a  purse-string  suture;  by  reefing  the  capsule  with  silkworm- 
gut;  by  incising  the  capsule  longitudinally  and  overlapping  the  inner  edge 
over  the  outer  edge  with  silver  wire  sutures.  If  the  joint  is  opened,—  and  in 
most  cases  it  is  advisable  to  do  so, — all  loose  bodies,  fringes,  and  pedunculated 
growths  may  be  removed.  The  cut  muscles  and  the  skin  are  then  sutured 
and  the  upper  extremity  immobilized  for  six  to  eight  weeks,  after  which  passive 
motion  may  be  used.  Whtn  the  dislocation  is  posterior,  an  incision  three 
inches  long  should  be  made  along  the  posterior  border  of  the  deltoid,  exposing 
the  capsule,  which  should  be  sutured  as  in  the  foregoing  description. 

Obstetric   Paralysis. 

Obstetric  paralysis  is  the  term  used  to  designate  the  partial  or  complete 
paralysis  which  is  sometimes  seen  follo^ving  prolonged  labor  or  instrumental 
delivery.     It    may    occasionally    occur    after   normal   labor.     Traction    made 


NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  485 

upon  the  head  in  head  presentation  or  upon  the  body  in  breech  presenta- 
tions is  the  exciting  cause.  It  may  also  occur  during  extreme  rotation  of 
the  head. 

Pathology. — The  pathologic  lesions  present  may  be  a  rupture  of  the 
two  upper  roots  (fifth  and  sixth  cervical)  of  the  brachial  plexus.  Stone  has 
shown  that  when  traction  is  made  upon  the  shoulder  the  upper  two  roots  are 
made  very  tense  and  then  rupture  whUe  the  three  lower  roots  remain  lax.  The 
muscles  involved  are  usually  the  biceps,  the  deltoid,  and  the  supinators  of 
the  forearm. 

Symptoms. — The  condition  is  present  from  birth.  The  attitude  is 
characteristic,  the  arm  being  held  slightly  backward  and  slightly  abducted, 
while  the  hand  is  extremely  pronated  and  the  fingers  flexed.  That  the  paralysis 
is  not  complete  is  shown  by  the  movements  possible  in  certain  directions,  and 
occasionally  there  is  some  motion  in  the  flexors  and  extensors  of  the  forearm. 
The  shoulder  itself  is  absolutely  powerless.  As  time  goes  on,  the  extremity 
does  not  grow  as  rapidly  as  its  fellow,  so  that  when  adult  life  is  reached  there 
may  be  several  inches  of  shortening.  If  the  condition  goes  untreated,  the 
structures  about  the  joint  become  markedly  atrophied  and  relaxed  so  that 
the  condition  may  in  time  simulate  congenital  subluxation. 

Prognosis.— The  prognosis  in  cases  of  complete  paralysis  that  are  not 
treated  or  do  not  improve  rapidly  within  two  to  three  months  is  very  bad.  In 
most  cases  recoverv  is  only  partial.  There  are  restriction  of  most  movements, 
atrophy  of  certain  groups  of  muscles,  and  retardation  in  growth  of  the  entire 
extremity. 

Treatment. — This  consists  in  absolute  rest  in  the  early  cases  until  all 
swelling  and  tenderness  have  disappeared.  The  forearm  should  be  supported 
in  a  sling,  and  if  necessary  a  pad  in  the  axilla  to  lessen  the  tendency  to  laxity 
of  the  capsule  and  subluxation.  The  entire  extremity  should  be  thoroughly 
massaged  daily,  the  joints  should  be  passively  moved  several  times  daily,  and 
galvanic  electricity  applied  to  the  aft'ected  muscles  three  times  a  week.  If  dis- 
location occurs  as  a  result  of  neglectful  or  faulty  treatment,  it  should  be  reduced 
and  the  tone  of  the  muscles  kept  up  as  much  as  possible.  If  muscular  con- 
tractures occur,  they  should  be  overcome  by  myotomy.  Some  good  results 
may  follow  transplantation  of  tendons,  especially  in  the  forearm,  so  as  to  over- 
come the  marked  pronation  and  flexion. 


486  ORTHOPEDIC  SURGERY. 

Congenital  Elevation  of  the  Scapula. 

Synonyms. — Sprengel's  deformity;  Angeborener  Hochstand  der  Scapula; 
Surelevation  congenitale  de  I'omoplate. 

Congenital  elevation  of  the  scapula  is  a  rather  rare  deformity.  The  con- 
dition consists  of  an  abnormal  elevation  of  the  scapula  above  the  level  of  its 
fellow.  The  deformity  may  be  moderate  and  consist  only  of  inward  rotation 
of  the  lower  angle  of  the  scapula,  or  aU  the  structures  of  the  shoulder-joint 
may  be  elevated.  Lateral  curvature  is  present  in  nearly  all  cases,  the  concavity 
being  on  the  side  opposite  the  deformity.  The  normal  motions  of  the  scapula 
are  limited  and  abduction  in  some  cases  is  not  possible  beyond  loo  degrees 
from  the  vertical  line.  In  some  cases  there  are  other  congenital  deformities, 
as  torticollis  and  asymmetry  of  the  face.  Wilson  and  Rugh  report  two  cases 
in  which  the  posterior  border  of  the  scapula  was  attached  by  a  bony  process 
to  the  spine  of  the  seventh  cervical  vertebra,  and  Goldthwait  and  Painter  report 
one  case  in  which  there  was  a  direct  articulation  between  the  upper  angle  of 
the  scapula  and  the  vertebrae.  KoUiker  and  Hoffa  report  four  other  cases 
in  which  the  upper  angle  of  the  scapula  was  bent  forward  and  had  been  diagnosed 
as  exostoses.  The  upward  displacement  of  the  scapula  varies  from  one-half 
to  two  and  a  half  inches  in  patients  under  ten  years;  in  those  older  it  varies 
from  one  to  four  and  a  half  inches.  Males  are  affected  more  frequently  than 
females,  and  cases  of  bilateral  deformity  are  reported  by  Honsell,  Wittfield, 
and  Milo. 

Pathology. — In  some  cases  the  affected  scapula  is  smaller  than  its  fellow 
(Goldthwait  and  Painter's  case).  There  may  be  an  attachment  of  the  scapula 
to  the  vertebrae  by  an  osseous  band  or  there  may  be  firm  union.  The  muscles 
usually  affected  are  the  trapezius,  the  rhomboids,  the  levator  anguli  scapulae, 
and  the  serratus  magnus.  Examination  of  these  muscles  shows  a  condition 
similar  to  that  found  in  torticollis,  or  an  almost  entire  absence  of  muscular 
tissue  which  has  been  replaced  by  fibrous  tissue. 

Statistics. — The  condition  was  first  described  by  Eulenberg  in  1863, 
and  received  general  attention  when  Sprengel,  in  1891,  reported  four  cases 
occurring  in  children  from  one  to  seven  years.  Pitsch  in  1898  reported  seven- 
teen cases  from  the  literature,  and  in  1900  Rager  reported  thirty-two  cases. 
Cases  have  also  been  reported  by  Wilson  and  Rugh,  Honsell,  Wittfield,  MUo, 
Goldthwait  and  Painter,  Kolliker  and  Hoffa,  and  Spillissy. 

Etiology. — Sprengel  and  others  consider  the  condition  to  be  due  to  a 
faulty  position  of  the  fetus  from  an  insufficiency  of  amniotic  fluid.     He  con- 


NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  487 

sidered  that  the  arm  was  held  behind  the  back  by  pressure  and  that  this  deformity 
always  recurred  after  birth  as  a  result  of  the  prolonged  intra-uterine  pressure. 
Kausch  thought  the  condition  was  due  to  some  defects  in  the  lower  part  of 
the  trapezius  muscle.  Chievizt  thought  that  the  deformity  could  be  accounted 
for  by  the  fact  that  the  upper  extremity  arises  as  a  cervical  appendage  and 
during  early  fetal  life  remains  in  an  elevated  position,  and  that  any  intra-uterine 
condition  interfering  with  its  proper  descent  might  be  the  cause  of  the  deformity. 
Kirmisson  considered  the  condition  to  be  due  to  an  arrest  of  development  of 
the  scapula,  as  in  some  cases  the  affected  scapula  is  smaller  than  its  fellow. 
Cases  of  acquired  elevation  of  the  shoulder  due  to  rachitis  have  been  reported 
by  Kolliker,  Gross,  and  Bender. 

Treatment. — When  cases  are  seen  early  the  treatment  should  consist 
in  open  division  of  the  contracted  muscles.  If  bony  union  exists  between 
the  scapula  and  the  vertebrae  it  should  be  removed.  When  the  superior  inner 
angle  is  bent  markedly  forward  a  portion  may  be  removed  if  it  interferes  with 
reposition  of  the  scapula.  After  union  has  taken  place  there  is  at  times  a 
tendency  for  slight  recurrence,  which  should  be  prevented  by  massage  and 
active  and  passive  movements.  There  is  often  a  tendency  to  increase  of  the 
scoliosis  present  if  the  condition  remains  untreated.  In  adults  if  the  limitation 
of  motion  is  only  moderate  and  is  not  increasing,  very  little  good  will  be  ob- 
tained by  operation.  In  patients  who  have  been  operated  upon,  there  is  usually 
considerable  difficulty  in  holding  the  scapula  in  its  normal  position. 

Congenital  Absence  of  the  Clavicle. 

This  is  an  extremely  rare  condition.  The  defect  may  be  a  complete  ab- 
sence of  one  or  both  clavicles,  but  there  is  usually  a  rudimentary  portion  near 
the  sternum.  This  portion  may  vary  from  2  to  3  inches.  The  condition 
does  not,  as  a  rule,  cause  any  functional  disturbance,  and  its  presence  is  dis- 
covered by  accident.  The  cause  is  due  to  lack  of  development  in  utero.  A 
characteristic  feature  of  the  condition  is  the  ease  with  which  the  shoulders 
may  be  approximated.  Most  cases  require  no  treatment.  If  any  loss  of  function 
occurs,  the  shoulders  may  be  strengthened  by  a  suitable  brace  to  hold  them 
back  into  normal  position. 

Rupture  of  the  Biceps  Muscle. 

Rupture  of  the  biceps  muscle  is  generally  the  result  of  too  great  a  demand 
made  upon  it  during  contraction  or  to  local  disease.     It  is  seen  almost  exclusively 


488  ORTHOPEDIC  SURGERY. 

in  men  whose  work  is  very  laborious,  and  while  endeavoring  to  lift  heavy 
weights  suddenly  produce  a  partial  or  complete  tear  of  the  muscle.  It  some- 
times occurs  when  there  is  a  general  degenerative  process  of  the  muscular 
system,  as  in  alcoholics,  when  there  is  a  local  degenerative  process,  as  in  fatty 
degeneration,  or  when  the  muscle  has  been  the  seat  of  a  previous  rupture 
or  when  it  has  been  weakened  by  the  removal  of  a  tumor. 

Statistics. — There  were  i8  cases  of  rupture  of  the  biceps  among  8i  cases 
of  general  muscular  rupture  reported  by  Maydl.  Sixty-six  cases  of  rupture 
of  the  biceps  are  reported  by  Loos;  of  these,  only  two  occurred  in  women. 
The  seat  of  rupture  in  56  of  these  cases  was  as  follows:  49  of  the  long  head; 
2  of  the  short  head;  i  of  both  heads;  3  of  the  distal  tendon;  and  3  of  the  common 
belly  of  the  biceps.  Of  the  49  cases  in  which  the  seat  of  rupture  was  of  the 
long  head,  10  were  in  the  upper  tendon,  20  at  the  musculotendinous  junction, 
and  17  in  the  belly  of  the  muscle. 

Symptoms. — ^At  the  time  of  the  injury  the  patient  feels  a  sharp  pain 
and  in  some  cases  heard  an  audible  snap  at  the  seat  of  rupture.  This  is  ac- 
companied by  partial  or  complete  loss  of  power  of  flexion,  especially  when 
the  forearm  is  in  a  position  of  supination.  This  occurs  on  account  of  the 
power  of  flexion  which  the  brachialis  anticus  has  when  the  forearm  is  pronated. 
Examination  shows  at  the  seat  of  rupture  a  deep  groove,  increasing  on  con- 
traction, between  the  torn  ends  when  efforts  are  made  at  flexion.  The  position 
of  the  rupture  is  shown  by  the  approximation  of  the  belly  of  the  muscle  on 
contraction  toward  the  elbow  if  high  up  and  vice  versa.  Considerable  hem- 
orrhage takes  place  at  the  seat  of  rupture,  which  is  shown  later  by  ecchymosis 
occurring  usuahy  on  the  inner  side  of  the  arm. 

Diagnosis. — This  depends  upon  the  history,  the  sudden  pain  and  snap, 
followed  by  the  appearance  of  the  groove  between  the  two  contracted  ends 
of  the  muscle  and  inability  to  flex  the  elbow  when  the  forearm  is  supinated. 

Prognosis. — This  depends  upon  the  cause  and  the  extent  of  the  rupture. 
When  the  rupture  occurs  in  normal  muscular  tissue  and  is  only  partial  the 
prognosis  without  operation  is  good.  When  complete  rupture  occurs  in  normal 
muscle  good  function  may  follow  non-operative  treatment  if  the  torn  ends 
can  be  held  in  good  apposition.  As  a  rule,  only  fibrous  union  occurs,  which 
in  time  may  stretch  or  be  the  cause  of  a  recurrence.  In  cases  due  to  general 
or  local  disease  the  immediate  prognosis  with  operation  is  good,  but  recurrence 
may  take  place;    without  operation,  the  functional  results  are  poor. 

Treatment. — Non-operative  treatment  consists  in  immobilizing  the  entire 


NON-TUBERCULOUS  DISEASE  OF  THE  SHOULDER-JOINT.  489 

extremity  and  by  approximating  the  torn  ends  by  means  of  bandages  to  lessen 
the  circumference  of  the  arm.  This  is  upon  the  principle  of  stroking  the  ends 
together,  which  can  be  done  when  no  contraction  is  present.  If  the  separation 
is  marked,  especially  in  young  subjects,  operation  is  advisable.  This  consists 
in  cutting  down  upon  the  muscles  at  the  seat  of  rupture  and  suturing  the  ends 
together  by  chromicized  catgut.  The  limb  should  then  be  immobilized  until 
sufficient  time  has  occurred  for  firm  union  to  take  place,  when  massage,  elec- 
tricity, and  gradually  passive  and  active  motion  may  be  instituted. 


CHAPTER  XII. 
TUBERCULOUS  DISEASE  OF  THE  ELBOW-JOINT. 

The  elbow-joint  is  affected  more  frequently  by  tuberculosis  than  either 
the  shoulder-joint  or  the  wrist-joint  and  is  fifth  in  order  compared  with  other 
joints.  Tuberculous  disease  of  the  elbow-joint  is  more  frequent  as  a  com- 
plication of  tuberculosis  of  the  viscera  than  the  other  joints. 

Statistics. — In  2292  cases  treated  at  the  Orthopedic  Department  of 
the  Hospital  of  the  University  of  Pennsylvania  the  elbow-joint  was  involved 
in  six  instances.  Whitman  states  that  there  were  56  cases  of  tuberculous 
elbow- joint  disease  in  1883  cases  of  joint  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled.  Females  are  affected  more  frequently  than  males 
and  the  left  more  often  than  the  right  side.  Konig  gives  the  age  as  follows: 
25  per  cent,  under  ten  years;  between  ten  and  twenty  years,  20  per  cent.;  be- 
tween twenty  and  thirty  years,  12  per  cent.;  between  thirty  and  forty  years, 
15  per  cent.;  between  forty  and  fifty  years,  8  per  cent.;  between  fifty  and  sixty 
years,  14  per  cent.;  and  between  sixty  and  seventy  years,  6  per  cent.  In  59 
cases  reported  by  Whitman  40  were  under  ten  years. 

The  primary  focus  may  be  in  the  synovial  membrane  or  in  one  of  the 
bones  forming  the  joint.  In  137  cases  Middeldorf  found  the  disease  primarily 
synovial  in  30  and  primarily  osseous  in  107.  Konig  found  the  disease  primarily 
synovial  in  29  per  cent,  and  primarily  osseous  in  71  per  cent,  of  137  cases. 
The  statistics  of  Scheimpflug  give  a  very  high  percentage  (92.8  per  cent.)  to 
the  primarily  osseous  form. 

In  the  osteal  form  the  ulna  more  often  contains  the  primary  focus  than 
the  other  bones.  Middeldorf's  statistics  of  107  cases  show  the  distribution 
as  foUows:  Ulna,  chiefly  olecranon,  49;  humerus,  33;  external  condyle,  4; 
humerus  and  ulna  together,  18;  radius,  3;  all  of  the  bones,  2;  and  radius 
and  ulna  together,  2.  In  the  81  cases  reported  by  Konig  the  primary  focus 
was  situated  as  follows:  humerus,  43;  olecranon,  36;  and  radius,  2.  Oilier 
observed  in  119  cases  that  the  olecranon  was  the  seat  of  the  primary  focus  in 
73,  the  humerus  in  33,  and  the  radius  in  12  cases. 

Pathology. — The  pathologic  changes  taking  place  in  tuberculous  elbow- 

490 


TUBERCULOUS  DISEASE  OF  THE  ELBOW -JO  INT. 


491 


joint  disease  are  identical  with  those  of  other  joints.  There  is,  however,  a 
marked  tendency  toward  suppuration  and  the  formation  of  abscesses  and 
sinuses.  The  capsule  of  the 
joint  being  rapidly  destroyed, 
abscesses  form  around  the  joint 
and  progress  down  the  fore- 
arm, in  the  intermuscular  septa. 
After  a  time  the  ligaments  and 


Fig.  362. — Ttjberculous  Disease  or  Ra-  Fig.    363. — Tuberculous    Arthritis  of  Elbow-joint 

Dius  AND  Ulna,  Involving  Elbow-joint.  showing  Disease  of  Radius. 


cartilages  are  destroyed,  leaving  a  joint  in  which  movements  are  possible  in 
all  directions. 


492  ORTHOPEDIC  SURGERY. 

Symptoms. — The  usual  phenomena  of  chronic  joint  disease — pain, 
swelling,  tenderness,  muscular  spasm  and  atrophy,  abscess  and  sinus  for- 
mation— are  present  here  as  in  other  joints.  There  is  perhaps  no  joint  so  fre- 
quently subject  to  tuberculous  disease  resulting  from  traumatism  as  the  elbow- 
joint.  The  symptoms  therefore  may  follow  those  resulting  from  injury. 
At  first  there  may  be  slight  swelling  with  obliteration  of  the  bony  outlines, 
moderate  induration  over  the  condyles  or  olecranon,  and  slight  limitation 
of  flexion  and  extension.  The  condition  develops  very  slowly.  The  primary 
osseous  foci  may  remain  dormant  for  some  time,  and  except  for  slight  induration 
over  the  affected  part  and  some  feeling  of  weakness  in  the  joint  all  symptoms 
may  be  absent  until  the  primary  focus  ruptures  into  the  joint  or  external  to 
it,  when  there  appears  marked  edema  around  the  joint,  which  increases  and 
is  made  quite  evident  by  contrast  with  the  atrophy  of  the  muscles  of  the  arm 
and  forearm.  This  edema  about  the  elbow,  on  account  of  its  shape  and  char- 
acteristics, has  been  called  the  "spindle-shaped  white  swelling."  Before 
this  takes  place,  however,  there  may  occur  marked  synovitis  as  a  result  of 
primary  infection  of  the  synovial  membrane  or  following  rupture  of  an  osseous 
foci  into  the  joint.  This  swelling  is  noticeable  by  the  protrusion  of  the  capsule 
over  the  head  of  the  radius  anteriorly  and  posteriorly  at  either  side  of  the  triceps 
tendon;    this  effusion  is  soon  marked  by  the  swelling  above  mentioned. 

Limitation  of  motion  begins  as  soon  as  effusion  takes  place  in  the  joint 
and  increases  with  the  progress  of  the  disease  and  becomes  marked  as  soon 
as  joint  motions  become  painful,  until  the  characteristic  deformity  results,  which 
generally  is  with  the  elbow  a  little  more  than  90  degrees  and  the  forearm  midway 
between  pronation  and  supination. 

Muscular  spasm  occurs  early  in  the  disease  and  is  one  of  the  causes  of 
the  limitation  of  motion.  This  varies  at  times  and  may  be  very  great  as  the 
muscular  effort  to  diminish  certain  starting  pains  causes  an  increase  in  the 
spasm  and  increased  diminution  of  the  range  of  flexion  and  extension. 

Muscular  atrophy  is  present  early  in  the  disease  and  varies  with  functional 
disability  of  the  joint.  It  is  in  marked  contrast  to  the  swelling  about  the  joint 
and  serves  to  intensify  the  latter. 

In  elbow-join.t  disease  there  is  a  marked  tendency  to  the  occurrence  of 
abscesses  and  fistulas.  As  a  rule,  these  abscesses  open  nearest  to  the  primary 
seat  of  the  infection.  If  the  condyles  are  primarily  aft'ected,  the  abscesses 
usually  open  just  below  the  condyles;  in  the  synovial  form  they  open  externally 
just  below  the  condyle;   when   the   olecranon   is  aff"ected,  they  point   usually 


TUBERCULOUS  DISEASE  OF  THE  ELBOW-JOINT.  493 

externally,  or  may  rupture  along  the  posterior  surface  of  the  forearm.  The 
destructive  process  may  be  so  extensive  that  the  soft  parts  are  riddled  with 
sinuses,  the  synovial  membrane,  ligaments,  and  articular  cartilages  are  destroyed, 
lateral  mobility  is  present,  so  that  the  entire  elbow  is  an  edematous,  bluish- 
gray,  shapeless  mass,  in  which  the  only  chance  to  save  the  patient's  life  is  by 
amputation. 

Prognosis. — This  depends  considerably  on  the  age,  on  the  degree  of 
involvement  of  the  tubercular  process,  on  the  patient's  general  condition,  and 
on  the  presence  or  absence  of  other  tuberculous  foci.  If  cases  are  seen  early 
and  in  childhood,  the  prognosis  for  cure  and  a  fair  range  of  motion  is  good. 
These  early  cases  in  childhood  do  very  well  under  conservative  treatment, 
and  while  the  duration  of  the  disease  is  usually  from  two  to  three  years,  the 
Joint  recovers  a  good  range  of  motion.  There  are  doubtless  many  cases  in 
childhood  which  recover  without  any  special  treatment.  Cases  that  are  seen 
in  which  the  joint  is  involved  to  only  a  limited  extent  or  those  in  which  extension 
takes  place  extra-articularly,  as  sometimes  occur  when  the  primary  focus  is 
in  the  olecranon,  generally  recover  with  a  more  useful  joint  under  mild  operative 
measures  than  those  of  extensive  involvement  of  the  intra-articular  and  extra- 
articular structures.  Patients  who  begin  treatment  before  the  general  condi- 
tions is  affected  by  the  local  process  do  much  better  than  those  in  which  the 
mixed  infection  has  taken  place,  extensive  involvement  is  present,  and  in  whom 
very  often  there  are  evidence  of  amyloid  degeneration  of  the  viscera.  This 
is  also  true  of  the  presence  or  absence  of  tuberculous  foci  elsewhere. 

The  functional  results  are  good,  even  though  ankylosis  takes  place,  provided 
the  elbow-joint  forms  a  right  angle.  In  this  position  the  function  of  the  arm 
is  but  little  impaired.  If  the  disease  occurs  during  childhood,  there  usually 
results  more  or  less  shortening. 

Treatment. — Constitutional  treatment  is  of  the  greatest  importance  and 
should  be  continued  for  a  long  period.  A  large  number  of  cases  retain  normal 
motion  when  conservatively  treated.  This  consists  in  immobihzation,  which 
in  some  cases  may  be  supplemented  by  injections  of  iodoform,  and  passive 
congestion.  The  entire  extremity  should  be  immobilized  in  the  position  which, 
should  ankylosis  occur,  will  be  the  most  useful.  The  position  of  election  is  at 
90  degrees,  with  the  hand  midway  between  pronation  and  supination.  At- 
tempts should  be  made  to  attain  this  position  as  soon  as  the  patient  begins 
treatment,  and  it  should  be  maintained  until  all  active  inflammation  has  ceased. 
This  position  may  be  maintained  by  means  of  slings  and  splints  made  of  wocd, 


494  ORTHOPEDIC  SURGERY. 

tin,  plaster-of-Paris,  and  leather.  Of  all  apparatus  for  keeping  the  parts  at 
rest,  preference  is  given  to  splints  made  of  plaster-of-Paris  or  molded  leather. 
These  splints  afford  protection  as  well  as  fixation,  can  be  used  until  the  parts 
decrease  in  size,  and  are  readily  replaced.  The  sling  is  a  very  efficient  means 
of  securing  immobilization,  but  should  always  be  supplemented  by  a  swathe 
including  the  chest  and  arm.  When  the  elbow  is  not  in  a  favorable  position, 
should  ankylosis  occur,  the  position  which  is  caused  by  muscular  spasm  may 
be  corrected  by  the  application  of  a  plaster-of-Paris  bandage  applied  from  the 
hand  to  the  axilla;  making  no  attempt  to  correct  the  deformity.  On  removing 
this  bandage  at  the  end  of  several  weeks  it  will  be  found  that  most  of  the  mus- 
cular spasm  has  disappeared,  so  that  a  good  functional  position  can  be  obtained 
without  undue  force  and  another  plaster-of-Paris  bandage  applied.  The  same 
result  may  be  obtained  by  a  sling  supporting  the  wrist.  The  hand  should  be 
carried  upward  to  the  neck  as  far  as  muscular  fixation  at  the  elbow  will  allow, 
the  head  should  be  carried  forward,  and  the  limb  supported  by  a  sling  passed 
around  the  neck  and  wrist.  After  several  days  the  head  will  be  erect,  and  this 
procedure  may  be  repeated  until  the  position  of  the  elbow  is  good  for  function 
if  ankylosis  should  occur.  If  ankylosis  is  present  when  the  case  is  first  seen 
and  the  position  is  very  poor  for  functional  use,  the  latter  may  be  corrected  by 
elastic  force  after  the  method  of  Weigel. 

Injections  of  iodoform  emulsion  are  of  value,  and  may  be  used  as  supple- 
mentary to  fixation.  When  the  capsule  becomes  very  tense,  it  may  be  aspirated 
and  refilled  by  an  emulsion  of  iodoform  (lo  per  cent.).  The  technic  of  injec- 
tion here  is  the  same  as  that  of  other  joints.  The  most  accessible  points  for 
inserting  the  needle  are  just  behind  the  head  of  the  radius,  at  the  side  of  the 
olecranon,  or  beneath  the  internal  condyle.  When  abscesses  have  formed, 
they  may  be  aspirated  and  treated  in  the  same  way.  Fistulas  may  be  filled 
with  the  emulsion  and  the  openings  tamponed.  All  writers  agree  on  the  value 
of  iodoform  in  treating  tuberculous  joint  disease,  especially  in  children,  in  whom 
more  radical  treatment  would  be  followed  by  disturbances  in  growth.  Bier's 
method  of  passive  congestion  has  some  advocates  who  use  it  in  some  cases  as  an 
aid  to  iodoform  injections. 

If  after  a  thorough  trial  of  conser\'ative  measures  no  improvement  is  mani- 
fest and  the  disease  progresses,  more  energetic  measures  should  not  be  delayed. 
They  consist  in  cureting  osseous  foci,  arthrectomy,  partial  and  complete  resec- 
tion, and  amputation. 

Small  fistulas  and  osseous  foci  should  be  thorouglily  cureted,  sequestra 


TUBERCULOUS  DISEASE  OF  THE  ELBOW-JOINT.  495 

removed,  and  attempts  made  to  secure  primary  union.  When  the  disease  is 
Hmited  to  the  synovial  membrane,  arthrectomy  may  be  performed  through  any 
of  the  incisions  used  for  resection.  All  granulation  tissue,  the  capsule  and 
cartilaginous  disks  should  be  carefully  removed  with  scissors.  If  small  areas 
of  diseased  bone  are  present,  they  may  be  excised  by  a  chisel. 

The  indications  for  resection  are  similar  to  those  of  other  joints.  ^Vhen 
the  condition  is  progressively  becoming  worse  under  conservative  treatment, 
and  especially  in  adults,  operative  treatment  is  indicated,  and  while  the  results 
of  excision,  particularly  in  the  elbow-joint,  are  not  so  good  as  those  of  more 
conservative  measures,  yet  if  the  condition  is  allowed  to  continue  there  soon 
comes  a  time  when  amputation  will  offer  the  only  means  of  saving  the  patient's 
life.     The  joint  may  be  opened  by  the  posterior  incision  inside  of  the  median 


Fig.  364. — Elbow-joint  Disease  after  Erasion. 

line,  extending  about  2I  inches  above  and  below  the  olecranon.  The  incision 
is  carried  down  to  the  bone,  the  periosteum  and  soft  parts  above  it  lifted  up 
from  the  bone  by  an  elevator.  Care  should  be  taken  to  preserve  the  integrity  of 
the  muscles,  and  particularly  the  lateral  ligaments.  The  articular  surfaces  of 
the  involved  bones  may  then  be  dislocated  and  resected  by  means  of  a  saw  and 
chisels.  Partial  resection  is  always  preferable  to  complete  resection  in  all 
cases,  particularly  if  the  operation  is  performed  during  childhood.  The  por- 
tions excised  should  always  be  limited  to  the  part  involved. 

So  many  modifications  of  the  typical  resection  are  possible  that  no  attempt 
can  be  made  to  give  any  set  rules  to  be  followed.  The  after-treatment  consists 
in  thorough  fixation  and  protection.  This  is  best  obtained  in  a  plaster-of-Paris 
splint  which  can  be  removed  if  necessary.     In  most  cases  ankylosis  is  desired, 


496  ORTHOPEDIC  SURGERY. 

SO  that  fixation  may  be  continued  an  indefinite  time  and  the  muscular  tone  may 
be  improved  by  massage  and  electricity.  If  the  muscles  and  ligaments  are 
well  preserved  and  only  a  partial  resection  was  performed,  passive  motion  may 
be  instituted  early  in  the  hope  of  obtaining  a  certain  degree  of  motion.  Re- 
section is  also  indicated  for  faulty  position  in  order  to  give  an  arm  that 
functionally  will  be  better  than  one  ankylosed  in  a  position  that  entirely  unfits 
it  for  use. 

The  indications  for  amputation  are  the  same  as  those  of  other  joints,  and 
while  it  is  rarely  necessary,  yet  when  extensive  destruction  of  the  capsule, 
ligaments,  and  cartilages  takes  place,  the  soft  parts  are  riddled  with  sinuses, 
and  the  patient's  general  condition  is  steadily  becoming  worse,  amputation 
is  urgently  demanded. 

Statistics  on  Resection. — Culbertson  records  290  cases  of  tuberculous 
wrist-joint  disease  which  recovered  after  resection  had  been  performed.  Of 
these,  the  joint  was  perfect  in  32  and  useful  in  196  instances.  The  statistics 
from  Kocher's  clinic  of  40  cases  treated  by  resection  were  reported  by  Osch- 
man.  Of  these  40  cases,  15  were  dead,  the  cause  being  tuberculosis  in  8  cases, 
other  causes  in  2,  and  unknown  in  5  instances.  Of  these  15  patients,  11  lived 
from  five  to  twenty  years.  No  patients  died  as  a  result  of  the  operation.  There 
was  complete  cure  in  96  per  cent,  of  cases.  In  64  per  cent,  of  these  the 
patients  were  able  to  use  the  arm  for  hard  work  and  in  36  per  cent,  they  were 
capable  of  only  light  work.  In  59  per  cent,  of  the  cases  that  had  a  complete 
cure  the  movements  of  the  elbow-joint  were  normal,  in  11  per  cent,  ankylosis 
was  present,  in  15  per  cent,  there  was  subluxation,  and  in  12  per  cent,  there 
was  a  loose  joint.  The  statistics  of  Konig  on  resection  are  as  follows:  In  those 
on  whom  complete  resection  Avas  performed  54  per  cent,  had  complete  recovery; 
in  8  per  cent,  the  recovery  was  incomplete;  and  38  per  cent.  died.  In  those 
on  whom  partial  resection  was  performed  there  was  complete  recovery  in  32 
per  cent.;  incomplete  recovery  in  8  per  cent.;  and  61  per  cent.  died.  The 
functional  results  given  by  the  same  writer  were  as  follows:  there  were  60  per 
cent,  of  recoveries  with  moderate  motion  and  good  power,  2>3  P^^  cent,  had 
ankylosis  and  fair  power,  and  in  seven  per  cent,  there  was  a  resulting  loose 
joint.  These  results  were  obtained  in  45  cases,  in  which  he  used  Langenbeck's 
operation  in  40  and  his  own  in  5  instances. 


CHAPTER  XIII.  : 

NON-TUBERCULOUS  DISEASES  OF  THE  ELBOW-JOINT. 

Free  Bodies  in  the  Elbow-joint. 

While  free  bodies  are  not  found  so  frequently  in  the  elbow-joint  as  in  the 
knee-joint,  yet  their  presence  is  rather  frequent  and  gives  rise  to  considerable 
inconvenience  and  impairment  of  the  joint.  They  may  be  entirely  free  in  the 
joint  or  may  be  attached  by  periosteum.  The  latter  form  is  often  seen  in  frac- 
tures of  the  head  of  the  radius.  Their  most  frequent  position  is  near  the  head 
of  the  radius,  in  the  coronoid  fossa,  and  in  the  olecranon  fossa. 

Etiology. — Free  bodies  may  be  due  to  fracture,  as  is  seen  in  the  chisel- 
fractures  of  the  head  of  the  radius.  They  are  sometimes  due  to  avulsion. 
Most  authorities,  including  Konig,  hold  that  traumatism  is  but  a  minor  etio- 
logic  factor  in  the  production  of  free  bodies.  They  claim  that  the  condition 
results  from  an  erosion  of  the  cartilage  or  pathologic  changes  in  the  bone,  so  that 
a  very  trifling  injury  is  sufficient  to  separate  the  diseased  portion  from  the  bone 
forming  a  free  body.  M.  Wilms  considers  that  the  majority  of  free  bodies  are 
due  to  an  injury  occurring  years  previously.  Martens  considers  them  to  be 
due  to  a  pathologic  change  which  he  calls  "osteochondritis  dissecans."  The 
free  bodies  usually  consist  of  cartilage,  but  rarely  may  consist  of  bone. 

Symptoms. — The  onset  varies  according  to  the  cause.  Usually  there 
may  be  symptoms  referred  to  the  joint  following  injury,  or  the  symptoms  may 
develop  gradually.  Pain  and  localized  tenderness  are  usually  present.  The 
capsule  may  be  distended  by  a  synovitis.  At  times  the  loose  body  may  be 
palpated.  The  most  characteristic  symptom  is  limitation  of  flexion  and  ex- 
tension. This  depends  upon  the  position  of  the  body;  when  it  is  present  in  the 
coronoid  fossa,  there  may  be  moderate  limitation  of  flexion,  and  when  in  the 
olecranon  fossa  extension  may  be  limited  lo  to  25  degrees.  Occasionally  pro- 
nation and  supination  may  be  interfered  with  if  the  body  is  near  the  head  of 
the  radius  or  attached  to  it  by  periosteum.  Crepitus  is  usually  present.  x\t 
times  there  may  be  excessive  callus  formation  at  the  seat  of  the  chipping  off  of 
the  portion  forming  the  free  body. 

Diagnosis. — This  depends  upon  the  history,  the  presence  of  a  movable 


498  ORTHOPEDIC  SURGERY. 

body  which  is  palpable,  limitation  of  motion,  and  the  results  of  an  .r-ray  exami- 
nation. 

Treatment, — When  the  symptoms  are  undoubtedly  those  of  a  free  body 
and  its  presence  can  be  demonstrated  by  the  rx^-ray  photograph,  the  removal  of 
the  free  body  is  indicated.  The  incision  necessary  will  vary  with  the  position 
of  the  body.  If  in  the  olecranon  fossa,  a  posterior  incision  will  readily  expose 
it.  If  in  the  coronoid  fossa  or  near  the  head  of  the  radius,  an  anterior  incision 
followed  by  careful  dissection  to  expose  the  capsule  will  be  necessary.  Care 
should  be  taken  not  to  injure  any  of  the  structures  in  the  cubital  space.  After 
removal  of  the  free  body  the  joint  usually  regains  its  normal  range  of  motion 
and  is  entirely  free  from  all  further  symptoms.. 

Cubitus  Varus  and  Valgus. 

Cubitus  varus  and  valgus  may  be  defined  as  those  conditions  in  which 
the  axis  of  the  forearm  when  fully  extended  deviates  more  or  less  than  normal 
from  the  longitudinal  axis  of  the  arm;  cubitus  varus  being  an  adduction  angle 
and  cubitus  valgus  an  abduction  angle  as  compared  with  the  normal.  There 
is  a  ph3'siologic  cubitus  valgus  present  in  all  people,  and  commonly  known  as  the 
"carrying  angle."  This  angle  may  be  accentuated,  and  varies  normally  in 
males  from  i  to  9  degrees  and  in  females  from  15  to  25  degrees;  so  that  the 
angle  formed  by  the  longitudinal  axis  of  the  arm  and  forearm,  which  physio- 
logically in  men  is  173  degrees  and  in  women  is  167  degrees,  may  vary  within 
the  above  limits.  This  physiologic  increase  in  the  angle,  according  to  the  in- 
vestigations of  Hiibscher,  takes  place  after  puberty,  and  is  not  caused  by  changes 
in  the  joint  itself,  but  occurs  as  a  result  of  outward  deviation  of  the  lower  end  of 
the  diaphysis  of  the  humerus.  The  greater  increase  in  females  may  be  ac- 
counted for  by  the  fact  of  the  relative  narrowness  of  the  shoulders  compared  with 
that  of  the  pelvis,  and  the  necessity  for  this  increase  so  as  to  render  a  useful 
"carrying  arm."  A  congenital  increase  of  the  normal  angle  may  be  due  to 
laxity  of  the  articular  ligaments  which  allow  of  hj^erextension.  M.  Wilms 
considers  that  cubitus  valgus  and  varus  may  occur  during  post-natal  gi^owth 
as  a  result  of  premature  ossification  of  one  or  the  other  of  the  upper  epiphyses  of 
the  ulna  or  radius,  thereby  creating  an  inequality  in  length  of  the  bones  of  the 
forearm,  which  in  turn  causes  the  abnormal  position  of  the  forearm. 

The  condition  is  sometimes  seen  in  early  childhood,  as  a  manifestation  of 
rachitis,  and  while  it  may  persist  for  a  long  time,  in  most  cases  it  disappears 
soon  after  all  weight  is  taken  off  the  arm. 


NON-TUBERCULOUS  DISEASES  OF  THE  ELBOW-JOINT.  499 

Cubitus  valgus  and  varus  may  be  due  to  fracture  of  either  condyle  of  the 
humerus,  to  injury  to  the  lower  epiphyseal  line  of  the  humerus,  and  to  rupture 
of  the  lateral  ligaments  of  the  elbow.  The  deformity  resulting  in  traumatic 
cubitus  varus  is  commonly  called  a  "gunstock  deformity." 

Treatment. — The  mild  forms  of  cubitus  varus  and  valgus  do  not  require 
any  treatment.  Severe  cases  due  to  deviation  of  the  lower  end  of  the  humerus 
may  be  corrected  by  a  cuneiform  osteotomy  of  the  shaft  of  the  humerus.  Cases 
which  are  due  to  inequahty  of  growth  of  the  radius  and  ulna  may  be  corrected 
after  puberty  by  removing  a  suitable  section  from  the  longer  of  the  two  bones. 
When  the  deformity  follows  a  fracture  of  either  condyle  of  the  humerus  the 
position  should  be  corrected  before  union  has  taken  place,  and  if  the  case  is 
not  seen  until  after  union  is  firm,  an  osteotomy  will  usually  overcome  the 
deformity. 

Olecranon  Bursitis. 

Synonym. — Miner's  elbow. 

Inflammation  of  the  olecranon  bursa  may  be  due  to  an  acute  chronic  or 
suppurative  process.  The  acute  condition  is  found  following  traumatism  and 
localized  septic  wounds  in  the  region  of  the  elbow.  Chronic  inflammation  is 
due  to  an  occupation  in  which  the  tip  of  the  elbow  is  subject  to  repeated  trauma, 
as  in  miners;  hence  the  synonym.  Suppurative  processes  take  place  as  a  result 
of  punctured  or  lacerated  wounds. 

The  symptoms  of  acute  and  chronic  bursitis  are  those  of  bursas  elsewhere. 
The  olecranon  bursa  is  fairly  large  and  is  situated  over  the  tip  of  the 
olecranon  process.  In  acute  inflammation  there  is  the  presence  of  an  elastic, 
fluctuating,  non-tender  swefling  in  the  region  of  the  bursa.  In  the  chronic 
form  there  is  added  a  sense  of  considerable  thickness  to  the  walls,  and  at  times 
there  may  be  felt  small,  irregular,  fibrinous  bodies.  In  the  suppurative  variety 
there  are  added  to  the  acute  form  local  heat,  tenderness,  redness  and  edema  of 
the  surrounding  soft  parts,  acute  noditis  of  the  axfllary  lymph-nodes,  and  perhaps 
some  increase  in  the  general  temperature. 

In  the  acute  form  treatment  consists  in  placing  the  limb  at  rest  and  exert- 
ing pressure  on  the  bursa  by  means  of  an  elastic  bandage  or  similar  means.  In 
chronic  olecranon  bursitis  the  bursa  should  be  dissected  from  the  surrounding 
structures  and  removed  or  incised,  its  cavity  thoroughly  cureted,  and  the  wound 
closed  in  the  hope  of  obtaining  primary  union.  In  suppurative  olecranon 
bursitis  the  treatment  consists  in  incision,  curetment,  and  drainasre. 


CHAPTER  XIV. 
TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT. 

Tuberculous  inflammation  of  the  wrist-joint  is  a  rare  affection  occurring 
about  as  frequently  as  chronic  shoulder- joint  disease.  It  is  rarely  seen  in  chil- 
dren, but  occurs  usually  in  adults.  Ridlon  states  that  children  with  S}^hilitic 
antecedents  are  at  times  subject  to  tuberculous  disease  of  the  wrist-joint.  Very 
often  in  adults  there  is  the  history  of  a  sprain  or  some  other  mild  injury  which 
did  not  at  the  time  cause  the  patient  any  inconvenience.  Tuberculous  disease 
of  the  WTist-joint  is  usually  accompanied  by  phthisis,  or  it  may  be  a  local  manifes- 
tation of  miliary  tuberculosis.  It  rarely  continues  any  length  of  time  without 
the  development  of  phthisis,  and  in  most  cases  the  t\vo  affections  are  well 
advanced  when  first  seen. 

Statistics. — In  5680  cases  of  orthopedic  disease  treated  in  the  Orthopedic 
Department  of  the  Hospital  of  the  University  of  Pennsylvania,  there  were 
10  cases  of  tuberculous  wTist-joint  disease.  In  919  cases  of  tuberculous 
joint  disease  collected  by  Che^Tie  from  the  statistics  of  Jaffe,  Schmalfuss,  Bill- 
roth, Menzel,  and  his  own  records,  the  wrist  and  hand  were  afi'ected  in  6 
instances.  Whitman  states  that  in  3105  cases  treated  in  the  out-patient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled  during  five  years  there  were 
4  cases  of  -RTist-joint  disease.  Karewski  states  that  in  990  cases  of  joint  disease 
occurring  during  childhood  the  wrist-joint  was  involved  in  31  instances.  Of 
43  cases  treated  by  excision  by  Oilier  there  were  none  under  thirteen  years  of  age. 
Pathology. — The  pathologic  changes  which  take  place  at  the  wrist-joint 
are  similar  to  those  of  other  joints.  On  account  of  the  extensive  arrange- 
ment of  the  s}-nonal  membrane  aU  parts  become  finally  involved.  As  a  rule, 
the  sheaths  of  the  tendons  become  secondarily  involved,  greatly  complicate  the 
disease,  and  add  materially  to  the  gravity  of  the  prognosis.  It  should  not  be 
forgotten  that  the  tendon-sheath  may  become  primarily  involved  and  closely 
resemble  disease  of  the  -wrist-joint.  The  disease  may  be  primarily  s\Tio\-ial  or 
osseous.  Cheyne  says  that  the  former  tj^e  prevails  at  this  joint,  but  in  most 
cases  the  primary  focus  is  difficult  to  find.     jNIoore  states  that  m  all  the  cases 

500 


TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT.  501 

which  he  has  operated  upon  the  primary  focus  was  osseous.  In  the  osseous 
form  the  primary  focus  may  be  in  the  radius,  carpal  bones,  or  metacarpals. 
The  symptoms  and  course  are  greatly  dependent  upon  the  origin  of  the  disease. 
Beginning  in  the  radius,  it  may  be  manifested  by  a  diffuse  involvement  of  the 
shaft  beyond  the  epiphyseal  line,  as  a  cone-shaped  focus  in  the  epiphysis,  or  it 
may  be  situated  under  the  cartUage.  When  the  disease  begins  in  the  carpus, 
it  may  be  localized  to  one  bone,  but  in  most  cases  several  bones  with  the  synovial 
membrane  are  early  involved.  When  the  bases  of  the  metacarpal  bones  are 
primarily  involved,  it  is  usual  for  the  disease  to  be  localized  and  extend  into  the 
shaft  rather  than  extend  into  the  joint. 

Symptoms. — The  first  symptoms  to  attract  notice  are  swelling  and  ten- 
derness about  the  joint.  Muscular  spasm  and  pain,  which  are  so  frequently 
present  in  tuberculous  disease  of  other  joints,  are  not  prominent  here  in  the  early 
stages.  The  swelling  is  dependent  upon  the  degree  of  involvement  of  the  joint 
structures.  When  it  is  localized  to  one  bone,  the  swelling  is  generally  circum- 
scribed. If  all  the  joint  structures  are 
involved,  the  swelling  surrounds  the 
entire  joint,  is  more  marked  on  the 
dorsal  surface,  and  when  the  tendon- 
sheaths  become    involved    extends   up 

Fig.  365. — Wrist-joint  Disease  (Ashhurst). 

and  down  the  forearm.  If  the  swell- 
ing becomes  very  diffuse  and  the  muscular  atrophy  marked,  there  is  generally 
present  the  characteristic  spindle-shaped  "white  swelling."  Muscular  atrophy, 
limitation  of  motion,  and  flexion  deformity  are  usually  well  marked.  Accompany- 
ing the  flexion  deformity,  the  fingers  become  straight  and  the  thumb  extended 
alongside  the  index-finger.  The  joint  surfaces  become  exceedingly  sensitive  to 
pressure.  Suppuration  occurs  in  many  cases  in  adults,  but  is  rare  in  children. 
Fistulas  form  usually  at  the  sides  of  the  extensor  tendons,  and  in  a  large 
majority  of  cases  finaUy  involve  the  tendon-sheaths.  At  the  site  of  the  fistulas 
there  generally  develops  secondary  inoculation  of  the  skin  with  the  develop- 
ment of  lupus  for  an  extensive  area  about  the  fistula.  Pulmonary  tuberculosis 
is  generally  present  either  when  the  case  is  first  seen  or  develops  later. 

Diagnosis. — This  depends  upon  the  history,  the  presence  of  tuberculous 
disease  elsewhere,  and  symptoms  of  increasing  functional  disability,  tenderness, 
limitation  of  motion,  sweUing,  muscular  atrophy,  suppuration,  and  extension  of 
infection  with  the  formation  of  cutaneous  tuberculosis.  A  diagnosis  is  more 
difficult  when  the  tuberculous  process  involves  only  one  or  two  bones  of  the  car- 


502  ORTHOPEDIC  SURGERY. 

pus,  but  all  doubt  -will  be  ended  b}'  the  results  of  an  .r-ray  examination.  The 
condition  is  to  be  distinguished  from  a  tenosynovitis  and  gonorrheal  arthritis 
at  the  wrist-joint. 

Prognosis. — The  prognosis  of  tuberculous  -VATist-joint  disease  is  always 
grave  on  account  of  the  presence  of  an  existing  tuberculous  condition  elsewhere, 
as  phthisis,  or  by  reason  of  the  tendency  of  secondary  infection  to  occur  with 
disease  of  the  wrist-joint.  Nearly  aU  cases  of  tuberculous  wrist-joint  disease  die 
of  pulmonary  tuberculosis.  In  children,  however,  the  prognosis  is  better,  as  the 
percentage  of  coexisting  phthisis  is  not  so  great;  yet  very  few  live  to  maturity. 
When  extensive  involvement  of  the  tendon-sheaths  takes  place  and  extensive 
suppuration  occurs,  the  only  means  of  prolonging  life  is  by  amputation,  and 
even  then  the  prognosis  is  very  bad. 

Treatment. — The  treatment  depends  upon  the  extent  of  the  disease,  the 
age,  and  the  general  condition.  In  no  condition  is  radical  surgery  more  justified 
than  in  tuberculous  \ATist-joint  disease  in  the  adult.  In  childhood  suppuration,  if 
it  occurs,  is  usually  circumscribed,  and  conservative  methods  give  good  results. 
The  general  health  should  be  improved  by  tonics,  outdoor  air,  and  plenty 
of  sunlight.  Conservative  treatment  consists  in  fLxation  in  a  plaster-of-Paris 
bandage  from  the  metacarpophalangeal  joint  to  the  elbow,  combined  with  a  sling 
to  support  the  hand  and  forearm.  If  flexion  deformity  is  present,  it  may  be 
gradually  corrected  by  the  successive  use  of  plaster-of-Paris  bandages  applied 
without  any  undue  eft'ort  being  made  to  correct  the  deformity.  After  removing 
each  bandage  at  the  end  of  two  weeks,  the  muscular  spasm  will  have  decreased 
to  such  an  extent  as  to  allow  partial  corrections  every  time.  As  ankj'losis  is  the 
most  favorable  result  to  be  expected,  the  wrist  should  be  placed  in  a  position  of 
moderate  dorsal  flexion,  this  being  the  best  position  for  use.  Bier's  method  of 
passive  congestion  may  be  foUowed  by  favorable  results  in  some  cases.  Injec- 
tions of  iodoform  emulsion  (lo  per  cent.)  are  often  of  value.  The  needle  can  be 
inserted  just  below  the  styloid  of  the  radius  and  ulna  to  either  side  of  the 
extensor  tendons.  Its  use  is  contraindicated  by  the  presence  of  sequestra.  It  is 
foUowed  by  excellent  results  in  the  treatment  of  cold  abscesses.  When  the  foci 
are  limited  to  one  bone,  as  the  epiphysis  of  the  radius  or  the  head  of  a  metacarpal, 
the  disease  may  be  arrested  by  curetment  or  partial  arthrectomy.  Wlien  sup- 
puration and  fistulas  are  present  in  the  adult,  radical  means  are  indicated,  on 
account  of  the  danger  of  pulmonary  tuberculosis. 

Of  operative  measures,  excision  and  amputation  only  should  be  considered, 
as  arthrectomy  is  almost  impossible  on  account  of  the  anatomic  structure  of  the 


TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT.  503 

joint.  Excision- is  to  be  recommended  when  the  general  health  is  good  and 
when  the  disease  is  not  very  extensive.  The  method  of  Lister  is  the  one  most 
frequently  used.  It  consists  of  a  dorsal  and  radial  incision.  It  should  be  ren- 
dered bloodless  by  employing  an  Esmarch  bandage.  All  the  diseased  struc- 
tures, including  the  articulating  end  of  the  radius,  all  the  carpal  and  heads  of  the 
metacarpal  bones.  The  wound  may  then  be  dusted  with  iodoform  powder  and 
closed,  hoping  to  obtain  primary  union.  After  a  sterile  dressing  has  been 
applied  a  plaster-of-Paris  bandage  extending  from  the  fingers  to  the  elbow  should 
be  applied.  No  attempt  should  be  made  to  secure  a  movable  joint.  Studs- 
gaard,  of  Copenhagen,  recommends  a  complete  splitting  of  the  hand  for  tuber- 
culous wrist-joint  disease.  The  incision  is  made  between  the  third  and  fourth 
metacarpal  bones,  and  is  continued  upward  between  the  os  magnum  and  unci- 
form and  between  the  semilunar  and  cuneiform  bones.  Both  the  superficial 
and  deep  pahnar  arches  are  cut  and  ligated.  This  method  allows  of  very  free 
access  to  the  carpus  and  has  been  successfully  used  in  this  country  by  Mynter. 

When  the  tendon-sheaths  are  extensively  involved,  the  general  condition 
is  poor,  and  the  disease  is  progressing  rapidly,  amputation  is  followed  by  better 
results,  and  aft'ords  more  relief  than  resection.  Amputation  should  always  be 
performed  when  pulmonary  tuberculosis  is  present,  when  the  patient  is  subject 
to  considerable  suft"ering  and  is  generally  debilitated.  While  the  prognosis  is 
very  poor  even  with  amputation,  the  patients  are  made  more  comfortable  for 
the  short  time  they  have  to  live  and  the  pulmonary  condition  often  shows  signs 
of  improvement. 

Statistics  on  Resection. — OUier  reports  17  cases  of  excision  of  the  wTist- 
joint  for  tuberculous  disease  in  which  the  results  were  excellent;  in  none  was 
subsequent  amputation  required.  Gross  states  that  his  mortality  was  11. 7 
per  cent,  for  excisions  and  12.8  per  cent,  for  amputations.  Bradford  and  Lovett 
state  that  in  a  series  of  79  cases  in  which  excision  was  performed,  in  8  per  cent, 
the  results  were  perfect,  in  46  per  cent,  useful  limbs  were  secured,  and  in  24 
per  cent,  the  results  were  worthless.  This  list  includes  partial  and  complete 
excision. 

Tuberculous  Disease  of  the  Metacarpals  and  Phalanges. 

Synonym. — Spina  ventosa. 

By  spina  ventosa  is  meant  a  tuberculous  disease  of  the  metacarpals  and  pha- 
langes affecting  the  epiph3'seal  end  of  the  shaft  and  rapidly  involving  the  entire 
medullary  substance  and  destroying  the  spongy  and  cortical  bone.     The  latter  is 


504  ORTHOPEDIC  SURGERY. 

constantly  being  replaced  by  a  peripheral  external  growth  from  the  periosteum, 
so  that  in  time  the  bone  becomes  very  much  increased  in  circumference,  spindle- 
shaped,  and  its  cavity  is  filled  vi^ith  boggy  granulation  tissue  in  which  are  frag- 
ments of  sequestrated  bone.  The  process  may  continue  until  the  entire  bone 
is  destroyed,  or  a  stage  of  repair  may  take  place,  a  sinus  form,  the  sequestra  be 
gradually  discharged,  and  in  time  the  parts  may  return  to  normal.  The  disease 
may  occur  in  only  one  bone,  but  is  generally  seen  as  a  multiple  lesion  occurring 
in  several  bones  of  the  same  or  fellow  joints.  It  is  a  disease  occurring  usually 
during  childhood,  and  the  metacarpal  bones  are  more  often  affected. 

Symptoms. — The  local  symptoms  are  those  of  swelling,  pain,  and  tender- 
ness. At  first  the  swelling  is  localized,  but  later  may  become  more  dift'use,  so 
that  the  function  of  the  tendons  is  interfered  with.  The  condition  when  involv- 
ing the  metacarpals  may  be  mistaken  for  tenosynovitis.  The  picture  of  spina 
ventosa  involving  the  phalanges  is  very  characteristic  and  can  hardly  be  con- 
fused with  any  other  condition  except  syphilitic  dactylitis. 

Treatment. — When  there  are  no  signs  of  suppuration,  the  treatment 
consists  in  immobilization  of  the  part  by  means  of  a  splint  extending  from  the  tip 
of  the  fingers  to  the  elbow  or  by  a  plaster-of-Paris  bandage.  If  suppuration 
occurs,  the  abscess  should  be  opened  and  only  as  much  of  the  diseased  bone  as 
will  separate  readily  should  be  removed.  The  cavity  should  then  be  drained. 
Care  should  be  taken  to  avoid  wounding  the  tendon-sheaths.  When  the  disease 
involves  the  phalanges,  it  may  be  necessary  to  perform  an  amputation  on  account 
of  the  deformity  and  disturbances  in  growth  which  often  follow  spina  ventosa. 


CHAPTER  XV. 
NON-TUBERCULOUS  DISEASES  OF  THE  WRIST-JOINT. 

Tenosynovitis. 

Anatomy. — The  bursas  about  the  wrist-joint  are  similar  in  character  to 
those  found  about  the  ankle-joint.  Nearly  all  of  them  consist  of  sheaths  formed 
by  reflections  of  synovial-like  membrane  from  the  fibrous  sheath  of  the  tendon 
on  to  the  tendon  itself.  Those  on  the  flexor  surface  cross  the  wrist  beneath  the 
anterior  annular  ligament  and  are  the  following:  (i)  One  for  the  flexor  longus 
pollicis,  which  extends  almost  to  the  insertion  of  this  tendon.  (2)  A  bursa  for 
the  tendons  of  the  flexor  sublimis  digitorum,  which  are  divided  into  four  parts. 
(3)  A  large  bursa  for  the  tendons  of  the  flexor  profundus  digitorum,  which  usu- 
ally connects  with  that  for  the  sublimis  tendons.  The  sheaths  of  these  tendons 
are  prolonged  along  the  tendons  to  the  index,  middle,  and  ring  fingers  only  to  about 
the  middle  of  the  palm  of  the  hand,  but  continue  along  the  tendons  of  the  fifth 
finger.  The  bursa  usually  connects  with  the  sheath  of  the  flexor  longus  pollicis, 
and  together  they  are  known  as  the  great  carpal  bursa.  The  synovial  sheaths 
of  the  tendons  to  the  index,  middle,  and  ring  fingers  extend  from  the  heads  of  the 
metacarpal  bones  to  the  middle  of  the  distal  phalanges  and  do  not  communicate 
with  the  great  carpal  bursa.  (4)  There  is  a  small  round  bursa  connected  with 
the  flexor  carpi  ulnaris  and  separating  it  from  the  internal  lateral  ligament. 

The  tendons  on  the  extensor  surface  of  the  wrist  pass  beneath  the  posterior 
annular  ligament  through  six  compartments.  Each  of  these  compartments 
has  a  synovial  lining  which  extends  well  above  and  below  the  annular  ligament. 
From  within  outward  they  contain  the  following  tendons:  the  extensor  carpi 
ulnaris,  the  extensor  minimi  digiti,  ihe  extensor  communis,  the  extensor  indices, 
the"  extensor  secundi  intemodii  pollicis,  the  extensor  carpi  radialis  longior  and 
brevior,  the  extensor  primi  internodii  pollicis,  and  the  extensor  ossis  metacarpi 
pollicis. 

The  sheaths  and  their  inclosed  tendons  about  the  wrist-joint  may  be  subject 
to  acute,  chronic,  or  tuberculous  inflammation.  As  an  acute  condition  it  usu- 
ally results  from  injury  or  excessive  use,  or  it  may  be  due  to  gonorrhea.  It  is 
frequently  seen  in  carpenters,  washwomen,  and  locksmiths.     It  generally  affects 


506  ORTHOPEDIC  SURGERY. 

the  sheaths  of  the  extensor  tendons,  particularly  those  of  the  thumb.  Chronic 
tenosynovitis  may  result  from  repeated  acute  attacks  or  may  be  due  to  gonorrhea 
and  infectious  diseases.  Tuberculous  inflammation  very  frequently  attacks  the 
tendon-sheaths  and  may  be  the  only  manifestation  of  the  disease.  Purulent 
inflammation  may  involve  the  tendon-sheaths  and  carpal  bursa  and  cause 
extensive  destruction  of  the  sheaths  and  tendons  vi'ith  resulting  deformity  and 
disability  of  the  hand. 

Pathology. — In  the  acute  cases  there  is  marked  congestion  of  the  walls  of 
the  sheaths,  accompanied  by  an  excessive  outpouring  of  serum  and  fibrin.  As 
the  former  becomes  absorbed  the  latter  forms  adhesions  between  the  two  layers 
of  the  sac,  causing  the  fine  crepitation  which  is  so  characteristic  of  the  condition. 
In  the  chronic  non-tuberculous  form  there  is  marked  thickening  of  the  walls  of 
the  sheath,  adhesions  occur  between  the  apposed  surfaces,  and  in  places  there 
may  be  calcareous  deposits.  Tuberculosis  may  be  present  in  any  of  the  three 
following  forms:  (i)  as  a  serous  effusion;  (2)  with  "rice  bodies";  (3)  in  the 
fungous  variety.  In  the  latter  form  there  is  complete  destruction  of  the  tendon- 
sheaths,  the  cavity  being  filled  with  necrotic  tissue  and  pus. 

In  the  purulent  variety  affecting  the  flexor  tendon-sheaths  infection  is  self- 
limited  when  it  involves  the  sheaths  of  the  index,  middle,  and  ring  fingers;  but 
when  it  involves  the  bursae  of  the  thumb  and  little  finger,  it  rapidly  spreads 
throughout  the  great  carpal  bursa  and  extends  up  the  forearm  and  causes  early 
and  rapid  destruction  of  all  the  flexor  sheaths. 

Symptoms. — In  the  acute  variety  there  is  pain  on  voluntary  extension  or 
flexion,  with  moderate  swelling  t)f  the  sheaths  affected,  combined  with  crepi- 
tation and  moderate  tenderness.  In  the  chronic  and  tuberculous  varieties 
there  is  marked  swelling  along  the  region  of  the  tendon-sheaths  affected,  ^^^len 
this  is  marked  and  involves  the  great  carpal  bursae,  there  is  considerable  bulging 
above  and  below  the  anterior  annular  ligament,  which  resembles  an  hour-glass 
in  shape.  It  is  possible  in  some  cases  to  detect  the  presence  of  rice  bodies.  In 
the  purulent  form  if  the  thumb  or  fifth  finger  is  the  seat  of  the  original  infection 
there  may  be  progressive  increase  in  size  of  the  part  involved  with  a  similar  con- 
dition noticeable  below  the  wrist  and  later  extending  above  the  wrist.  There 
is  also  marked  lymphangitis,  enlargement  of  the  epitrochlear  and  axillary  lymph- 
nodes,  and  constitutional  symptoms  of  infection.  The  resulting  deformity 
following  suppurative  tenosynovitis  is  very  bad.  When  the  wounds  finally 
heal,  the  fingers  and  thumb  and  wrist  are  markedly  flexed,  motion  is  limited  to 
slight  flexion  and  extension,  muscular  atrophy  is  usually  weU  marked,  and  the 


NON -TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT.  507 

soft  parts  especially  of  the  hand  are  swollen,  reddish-blue,  cold,  and  often  con- 
tain sinuses  surrounded  by  sluggish  granulation  tissue.  The  end-result  of  such 
a  condition  is  a  hand  that  is  practically  useless  for  any  kind  of  work. 

Diagnosis. — The  diagnosis  depends  upon  the  swelling,  localized  to  the 
region  of  the  tendon-sheaths;  the  crepitus,  which  is  present  only  on  voluntary 
muscular  effort;  the  moderate  tenderness;  the  presence  of  "rice  bodies,"  felt 
on  palpation  in  the  tubercular  cases;  and  by  the  history  of  excessive  muscular 
action  or  of  an  acute  infection. 

The  condition  may  be  confused  with  tuberculous  wrist-joint  disease.  It  is 
differentiated  from  the  latter  by  the  fact  that  the  swelling  is  not  so  evenly  dis- 
tributed to  the  region  of  the  joint,  but  is  generally  confined  to  one  or  more  tendon- 
sheaths  and  extends  along  the  course  of  the  involved  tendons  up  and  down  the 
forearm  and  hand.  Muscular  atrophy  is  not  so  marked.  The  tenderness  is 
present  on  direct  pressure  and  is  not  produced  by  pressing  the  joint  surfaces 
together.  Deformity,  if  present,  is  entirely  different  from  that  of  tuberculous 
wrist-joint  disease,  and  any  limitation  of  motion  present  is  not  due  to  changes 
in  the  joint. 

Treatment. — The  treatment  of  the  acute  form  of  tenosynovitis  consists  in 
immobilization  on  an  anterior  or  posterior  wood  splint  extending  from  the  finger- 
tips to  the  elbow.  This  should  be  supplemented  by  large  doses  of  sodium  sali- 
cylate, which  seems  to  act  favorably  in  this  condition.  Rest  of  the  part  may  also 
be  obtained  by  means  of  adhesive  plaster  strapping  so  applied  as  to  cause  com- 
pression and  to  prevent  motion  of  the  involved  tendon-sheaths.  After  five  to 
seven  days'  immobilization  all  symptoms  will  have  disappeared.  Occasionally 
in  the  acute  form  due  to  gonorrhea  pain,  tenderness,  and  swelling  may  be  so 
great  as  to  require  aspiration  of  the  inflammatory  exudate.  The  part  should 
then  be  immobilized  for  two  to  three  weeks,  when  massage,  baking,  and  passive 
motion  should  be  instituted. 

The  chronic  form  of  tenosynovitis  at  times  yields  to  prolonged  baking  with 
hot  air,  massage,  and  passive  motion,  but  most  cases  require  incision  and  the 
injection  of  some  astringent  solution,  as  nitrate  of  silver  (i  per  cent,  solution), 
followed  by  compression,  or  the  entire  sheath  may  be  removed. 

Tuberculous  tenosynovitis  requires  very  persistent  treatment.  As  a  rule, 
the  condition  tends  to  progress  from  a  serous  variety  to  the  form  in  which  ' '  rice 
bodies"  are  found,  and  then  to  complete  destruction  of  the  entire  sheath. 
Injections  of  iodoform  emulsion  (lo  per  cent.)  have  been  followed  in  the  serous 
form  by  very  good  results.     When  "rice  bodies"  are  present,  the  sheaths  may 


508  ORTHOPEDIC  SURGERY. 

be  opened  and  attempts  made  to  wash  out  the  "bodies"  by  salt  solution,  after 
which  astringent  injections  may  be  used,  followed  by  compression.  This  may 
be  followed  by  complete  cure,  but  most  cases  in  which  there  are  "rice  bodies" 
and  those  where  the  entire  sheaths  are  destroyed  require  complete  extirpation 
of  the  sheaths. 

Purulent  tenosynovitis  calls  for  early  and  radical  incisions.  If  the  great 
carpal  bursa  is  not  involved,  which  may  be  predetermined  by  the  finger  in  which 
the  infection  begins,  a  single  incision  or  perhaps  two  incisions  vn\l  afford  suffi- 
cient drainage.  If,  however,  the  great  carpal  bursa  is  involved  and  the  swelling 
and  fluctuation  extend  up  the  forearm  under  the  anterior  annular  ligament,  the 
only  hope  of  obtaining  a  useful  hand  lies  in  making  multiple  incisions  below 
and  above  the  annular  ligament  and  establishing  free  drainage  until  the 
wounds  are  entirely  healed.  The  resulting  deformity  mentioned  above  should 
be  treated  by  massage,  baking  with  hot  air,  passive  and  active  motion.  In 
some  cases  the  destructive  process  in  some  of  the  fingers  may  be  so  great  as  to 
necessitate  amputation. 

Ganglion. 

Ganglion  is  the  term  applied  to  a  smooth,  fluctuating,  usually  spheric  and 
occasionally  lobulated  tumor,  situated  upon  the  dorsum  of  the  wrist.  Ganglia 
are  generally  separated  from  the  joint  by  a  thin  septa  and  are  nearly  always 
attached  to  one  or  more  tendon-sheaths.  They  are  fairly  movable  imder  the 
skin  and  vary  in  size  from  that  of  a  pea  to  that  of  a  large  walnut.  They  occur 
generally  in  youth,  are  more  common  in  females,  and  may  at  times  involve  both 
wrists  and  ankles  at  the  same  time. 

Etiology. — Various  theories  based  upon  personal  investigations  have  been 
advanced  from  time  to  time  to  account  for  the  formation  of  ganglia.  Gosselin, 
Teichmann,  and  v.  Volkmann  regarded  ganglia  as  retention  cysts  formed  by 
the  protrusion  of  diverticula  from  the  synovial  membrane  of  the  joint,  which 
after  a  time  become  entirely  separated  from  the  latter  by  adhesive  inflammation 
taking  place  within  the  pedicle  and  the  conversion  of  the  synovial  fluid  into  a 
thick  gelatinous  material.  Other  authorities,  includmg  Virchow,  Riedel,  and 
Ledderhose,  maintain  that  certain  forms  of  ganglia — colloid  cysts — are  formed 
by  the  coalescence  of  a  number  of  small  cysts  which  have  their  origm  from  the 
spaces  in  the  cellular  tissue  about  the  tendon-sheaths.  It  is  often  shown  in  dis- 
secting out  gangUa  from  the  surrounding  structures  that  on  cutting  the  pedicle 
there  generally  occurs  an  escape  of  S)movial  fluid,  and  this  fact  of  itself  shows 


NON-TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT.  509 

the  intimate  relation  of  the  ganglia  with  the  joint  cavity.  It  is  considered  by  most 
authorities  that  the  adhesions  between  the  ganglia  and  tendon-sheaths  is  sec- 
ondary. 

Symptoms. — The  subjective  symptoms  of  ganglia  are  generally  nil. 
Their  presence  rarely  ever  causes  any  functional  disturbance.  Objectively 
there  is  noticed  an  increasing,  painless,  fluctuating  tumor,  occurring  generally 
on  the  posterior  aspect  of  the  wrist-joint.  They  are  more  frequent  on 
the  radial  side,  and  may  present  between  any  of  the  tendons.  Konig 
states  that  they  occasionally  produce  discomfort  and  functional  disturbance 
in  pianists  when  present  near  the  radial  styloid  on  the  posterior  aspect  of 
the  wrist. 

Treatment. — The  treatment  may  be  classed  under  three  heads:  (i)  con- 
servative means;  (2)  methods  to  cause  obliteration  of  the  sac;  and  (3)  extir- 
pation. 

By  conservative  means  attempts  are  made  to  rupture  the  sac  and  to  cause 
obliteration  by  the  slight  inflammatory  reaction  which  may  occur.  This  crush- 
ing may  be  performed  by  forcible  crushing  with  the  thumb,  a  heavy  book,  or  a 
hammer.  After  this  is  done  a  pad  with  a  solid  back  is  placed  over  the  former 
swelling  and  constant  pressure  is  produced.  Under  this  method  of  treatment 
the  ganglion  is  liable  to  recur. 

The  methods  used  to  cause  obliteration  of  the  sac  are:  (i)  aspiration  fol- 
lowed by  the  injection  of  tincture  of  iodin  or  nitrate  of  silver  (i  per  cent,  solution) ; 
(2)  subcutaneous  discission  with  a  tenotome;  (3)  the  introduction  of  a  catgut 
suture  through  the  ganglion,  allowing  the  fluid  to  escape  and  leaving  the  suture 
in  place  for  several  days;  and  (4)  splitting  the  ganglion  and  packing  the  cavity 
with  gauze,  allowing  it  to  heal  by  granulation.  While  the  sac  is  often  obliter- 
ated by  these  means,  there  is  always  the  danger  of  infection  occurring  and  pro- 
ducing a  secondary  suppurative  arthritis  or  tenosjmovitis. 

Extirpation  offers  the  only  positive  means  of  preventing  recurrence.  Thor- 
ough aseptic  precautions  should  be  used.  If  possible,  the  sac  should  be  dis- 
sected from  the  surrounding  structures  without  being  opened,  and  the  wound 
closed,  expecting  primary  union  to  take  place.  A  pressure  bandage  and 
an  anterior  splint  from  the  fingers  to  the  elbow  should  be  applied  outside  the 
sterile  dressing.  In  seven  to  ten  days  the  wound  will  be  healed  and  everything 
except  a  small  protective  dressing  of  sterile  gauze  may  be  removed. 


510  ORTHOPEDIC  SURGERY. 

Sprain  of  the  Wrist. 

Under  the  indefinite  term  of  sprain  are  included  all  injuries  about  the  wrist- 
joint  caused  by  indirect  violence  which,  however,  is  not  sufficiently  forcible  to 
cause  a  fracture  or  dislocation.  The  condition  is  caused  most  frequently  by 
falls  upon  the  hand  or  by  forced  rotary  movements. 

The  anatomic  lesion  may  be  a  slight  tear  of  the  synovial  membrane,  tears 
and  stretching  of  ligaments,  displacement  or  tears  of  tendons,  and  fracture  of 
cartilages  or  avulsion  of  small  fragments  of  bone.  Very  often  fractures  of  the 
lower  end  of  the  radius,  especially  those  entering  the  joint,  are  mistaken  for 
sprains. 

Symptoms  of  Acute  Sprain. — Following  the  injury,  rapid  swelling  takes 
place,  which  may  be  due  only  to  an  effusion  into  the  wrist-joint;  or  when  the 
tendons  and  their  sheaths  are  involved,  the  swelling  is  not  confined  to  the  joint, 
but  occurs  also  as  a  result  of  effusion  into  the  tendon-sheaths.  Pain  is  present 
from  the  beginning,  and  is  increased  by  motion.  Tenderness  is  generally  local- 
ized to  the  points  of  local  injury  and  is  often  a  means  of  determining  accurately 
the  nature  and  seat  of  the  sprain. 

Chronic  Sprain. — The  symptoms  of  chronic  sprain  are  generally  pro- 
longed weakness  and  disability  at  the  wrist-joint.  Many  cases  are  due  to  the 
prolonged  immobilization  following  an  acute  sprain,  while  others  are  due  to  a 
fracture  of  the  lower  end  of  the  radius.  There  is  persistent  swelling,  usually 
slight  abduction  deformity,  and  limitation  of  motion  due  to  involvement  of  the 
tendon-sheaths. 

Diagnosis. — This  depends  upon  the  history  of  induced  violence,  the  nature 
of  the  swelling,  the  localization  of  tenderness.  In  all  severe  cases  or  in  those  in 
which  swelling  is  marked  or  deformity  is  present  an  .I'-ray  examination  should 
be  made  to  exclude  fractures. 

Treatment. — Acute  sprains  of  moderate  severity  should  be  treated  by  the 
application  of  adhesive  plaster  in  strips  extending  from  the  metacarpophalangeal 
joint  to  the  upper  third  of  the  forearm.  While  this  form  of  dressing  does  not 
entirely  mobilize  the  parts,  yet  in  most  cases  it  gives  sufficient  support  and  at  the 
same  time  allows  moderate  motion,  which  materially  hastens  the  absorption  of 
the  effusion.  If  compression  and  immobilization  are  desired,  they  may  be  ob- 
•tained  by  the  use  of  pasteboard  strip  splints  molded  to  the  part,  and  any  degree 
of  compression  may  be  obtained.  It  is  rarely  necessary  to  apply  a  wood  or 
plaster-of-Paris  splint.     After  all  swelling  and   tenderness  have  disappeared 


NON-TUBERCULOUS  DISEASE  OF  THE  WRIST-JOINT.  511 

restoration   to  normal   function  will  be   hastened   by  massage,  hot  air,  and 
passive  and  active  motion. 

Chronic  sprains  should  never  be  immobilized.  Very  often  an  :x;-ray  exami- 
nation will  reveal  a  fracture  which  may  necessitate  an  osteotomy  for  proper 
reduction.  If  no  fracture  is  present,  the  condition  should  be  treated  by 
massage,  hot  and  cold  douches,  counter-irritants,  hot  air,  and  passive  and 
active  motion. 


CHAPTER  XVI. 

NON-TUBERCULOUS  JOINT  DISEASES. 

While  many  of  the  affections  belonging  in  this  categoiy  have  been 
described  under  the  individual  joints  most  frequently  affected,  there  remain 
certain  infectious  and  malignant  diseases  v\^hich,  on  account  of  their  impor- 
tance or  general  distribution,  deserve  special  consideration.  These  include 
osteomyelitis,  the  various  forms  of  non-tuberculous  arthritis,  and  certain  con- 
stitutional conditions  affecting  the  articulations. 

Trauma  as  an  Etiologic  Factor  in  Joint  Diseases. 

The  popular  idea  among  the  laity  that  all  joint  disease  is  due  to  traumatism 
is  well  illustrated  by  the  number  of  patients  vi^ho  come  to  clinics,  claiming  that 
the  onset  of  the  joint  disease  for  which  they  desire  treatment  dates  back  to  some 
previous  injury.  This  is  true  not  only  in  the  cases  of  tuberculous  arthritis,  but 
also  in  cases  of  non-tuberculous  joint  disease.  This  popular  idea  is  strongly 
supported  by  clinical  observation  and  statistical  evidence.  That  various  joint 
lesions  are  localized  by  a  previous  trauma  of  moderate  degree  is  also  shown 
by  experiments  on  animals  which  are  supplemented  by  our  observations  in  the 
human  being.  Foci  of  disease  generally  are  localized  near  joints  which  have 
received  a  previous  slight  injury,  and  do  not  follow,  as  a  rule,  when  severe  injury, 
as  a  fracture,  has  occurred.  They  usually  follow  injuries  of  moderate  severity, 
as  sprains  and  contusions.  The  course  ascribed  in  the  formation  of  a  suitable 
field  for  the  setting  up  of  a  focus  of  disease  by  injuries  of  moderate  severity  is 
that  the  inflammatory  reaction  following  the  trauma  is  favorable  to  develop- 
ment of  a  localized  process,  while  the  process  is  so  active  following  severe  injuries 
that  the  infecting  agent  is  generally  destroyed.  In  acute  osteomyelitis  in  chil- 
dren there  is  usually  a  history  of  trauma.  If  patients  suffering  from  gonoiTheal 
urethritis  receive  a  moderate  injury  to  a  joint,  the  probability  of  a  gonorrheal 
arthritis  developing  is  very  great.  Van  Hansel  records  cases  of  patients  suf- 
fering from  syphilis  who  developed  syphilitic  periosteitis  and  gimima  following 
traumatism. 

512 


NON-TUBERCULOUS  JOINT  DISEASES.  513 

Synovitis. 

Synovitis  is  the  term  applied  to  an  inflammatory  process  of  the  joint  in  which 
the  synovial  membrane  alone  is  involved.  No  permanent  pathologic  process 
is  produced.  When  other  joint  structures  become  involved  in  the  condition 
and  permanent  changes  are  liable  to  take  place,  the  term  applied  to  such  a  con- 
dition is  arthritis. 

Three  forms  of  synovitis  are  recognized: 

1.  Acute  serous  synovitis. 

2.  Chronic  serous  synovitis. 

3.  Intermittent  joint  hydrops. 

Acute  Serous  Synovitis. 

Etiology. — ^Acute  serous  S3Taovitis  is  usually  the  result  of  direct  or  indirect 
violence  to  a  joint,  and  is  seen  most  frequently  following  sprains,  fractures, 
dislocations,  and  contusions.  It  may  be  the  result  of  a  punctured  wound  of 
the  joint  or  of  a  gunshot  wound  from  a  modern  rifle  bullet  or  a  sterile  foreign 
body.  It  sometimes  is  seen  in  the  early  stages  of  multiple  gonorrheal  arthritis 
before  the  infection  is  localized  in  one  joint;  it  occurs  in  rheumatism  and  in 
some  of  the  infectious  fevers,  as  scarlet  and  typhoid  fevers.  It  may  be  a  symp- 
tom of  urethral  fever,  and  occasionally  is  seen  in  connection  with  a  localized 
septic  process  near  the  joint,  as  in  carbuncle,  septic  wounds  of  the  soft  parts, 
and  erysipelas. 

Pathology. — Acute  serous  synovitis  begins  as  a  hyperemia  of  the  synovial 
membrane,  stasis  of  the  blood-current  occurs,  dilatation  of  the  capillaries,  and 
serous  exudate  containing  a  small  number  of  leukocytes  and  some  fibrin.  If 
due  to  traumatism,  there  may  be  hemorrhage  in  varying  degrees,  producing  a 
yellowish-red  or  red  color  in  the  effusion.  The  synovial  membrane  and  villi  are 
swollen  and  in  areas  may  show  localized  ecchymoses.  In  this  stage  under 
proper  treatment  the  fluid  will  become  absorbed  and  the  joint  surfaces  return 
to  their  normal  condition. 

Symptoms. — FoHowing  one  of  the  causes  enumerated  above,  there  is 
marked  change  in  contour  of  the  joint  surfaces  due  to  the  effusion.  The  normal 
furrows  are  obliterated.  Fluctuation  is  present  and  in  the  knee-joint  there  is 
floating  up  of  the  patella  and  baflottement.  The  joint  is  slightly  flexed,  or  in 
whatever  position  allows  of  the  greater  distention  of  the  capsule  of  the 
joint.  The  skin  is  normal  in  color,  tense,  and  there  may  be  slight  increase 
in    local   temperature.      Pain   and   tenderness   on   pressure    may   be   present 


514 


ORTHOPEDIC  SURGERY 


in  varying  degrees.     There  is  moderate  disability  and  some  loss  of  function 
present. 

Diagnosis. — This  depends  upon  the  history,  the  sudden  onset,  the  absence 
of  fever,  and  the  local  signs  of  increased  fluid  within  the  joint. 

Treatment. — The  treatment  of  acute  serous  synovitis  must  be  both  con- 
stitutional and  local.  A  saline  purge,  preceded  in  some  cases  by  a  mild  dose  of 
calomel,  may  be  followed  by  the  administration  of  nitrate  of  potash,  salicylate 
of  soda,  iodid  of  potash,  or  colchicum,  according  to  the  origin  of  the  affection. 

Locally,  rest,  either  upon  a  pillow,  in  a  plaster-of-Paris  bandage,  or  on  a 
suitable  splint,  and  usually  flying  blisters,  tincture 
of  iodin  applied  over  the  joint,  pressure,  and  moist 
heat,  will  be  attended  by  the  best  results.  A^'hen 
the  fluid  is  absorbed,  massage,  hot  and  cold 
douches,  hot  air,  passive  and  active  motion,  will 
soon  return  the  parts  to  a  normal  condition. 
Moderate  support,  as  given  by  a  flannel  or  elastic 
bandage  or  an  adhesive  plaster  dressing,  should 
be  used  for  some  time. 


Fig.  366. — Fimbriated  Growths  of 
THE  Synovial  Membrane. 


Chronic  Serous  Synovitis. 

Etiology. — Chronic  serous  synovitis  is  usu- 
ally the  result  of  an  improperly  treated  acute 
form;  it  may  be  due  to  repeated  acute  attacks, 
to  some  internal  derangement  of  a  joint,  to  a 
chronic  epiphysitis,  as  is  seen  in  the  beginning 
stages  of  a  tuberculous  joint  lesion,  or  to  some 
extra-articular  condition  which  interferes  with 
the  normal  functions  of  the  joint,  as  is  seen  in  ruptured  ligaments  and  tendons. 
Pathology. — In  addition  to  the  pathologic  changes  which  take  place  in 
acute  serous  synovitis,  there  occurs  moderate  thickening  of  the  synovial  mem- 
brane, h3^ertrophy  of  the  villi,  and  an  increased  amount  of  fibrin  in  the  effusion. 
The  latter  is  deposited  upon  the  synovial  membrane  and  cartUages,  and  later 
when  it  organizes  may  produce  adhesions.  The  effusion  is  usually  flocculent 
in  character  and  may  contain  portions  of  detached  villi.  Exfoliation  of  the  car- 
tilage may  occur. 

Symptoms. — In  addition  to  the  acute  symptoms,  there  is  marked  thick- 
ening of  the  periarticular  structure ;  the  swelling  may  vary  in  amount  at  various 


NON -TUBERCULOUS  JOINT  DISEASES.  515 

times.  Pain  is  generally  absent.  No  interference  with  the  joint  functions 
occurs  in  the  early  stages,  but  later  laxity  of  the  structure  results  until  moderate 
disability  is  present.  A  peculiar  leathery  crepitation  due  to  fibrinous  deposits 
is  often  present. 

Treatment. — General  medication  has  little  influence  upon  the  condition. 
Massage,  hot  and  cold  douches,  and  hot  air  may  have  some  effect  upon  the  effu- 
sion. Rest  in  a  suitable  splint,  combined  with  pressure  followed  by  the  use  of 
an  elastic  bandage,  will  in  most  cases  result  in  ultimate  cure.  When  the  condi- 
tion is  due  to  some  internal  derangement  of  the  joint  structure  or  a  tuberculous 
epiphysitis,  the  treatment  of  the  cause  of  the  effusion  will  usually  be  followed 
by  a  cure.  The  irrigation  of  the  joint  with  carbolic  acid  solution  (2  per  cent.), 
repeated  if  necessary,  followed  by  pressure  and  rest,  not  infrequently  causes  a 
cure.  Injections  of  an  emulsion  of  iodoform  (10  per  cent.)  may  be  used  with 
gratifying  results.  Injection  of  tincture  of  iodin  is  not  advised  on  account  of  the 
strong  reaction  which  usually  follows  and  of  the  questionable  results  obtained. 

Intermittent  Joint  Hydrops. 

This  is  a  rare  form  of  serous  synovitis  usually  involving  the  knee-joint. 
Other  joints  may  be  involved  at  the  same  time.  The  condition  consists  of 
swelling  due  to  effusion  or  extra-articular  edema.  It  may  or  may  not  follow 
traumatism.  The  peculiarity  of  the  condition  is  its  periodic  recurrence  at  regu- 
lar intervals  of  eleven  to  thirteen  days  or  some  other  regular  period.  The  attack 
continues  for  three  to  four  days,  after  which  the  parts  resume  their  normal  con- 
dition and  the  joint  functions  are  unimpaired.  The  affection  is  observed  in 
men  most  commonly  between  thirty  and  forty  years,  and  in  women  between 
twenty  and  thirty  years.  The  affection  is  about  equally  distributed  between  the 
two  sexes. 

The  condition  may  be  divided  into  two  classes:  (i)  symptomatic  and  (2) 
idiopathic. 

Symptomatic  Intermittent  Joint  Hydrops.— In  this  class  the  synovitis 
is  secondary  to  some  other  condition.  It  has  been  observed  most  frequently 
in  the  following  conditions:  (i)  acute  splenic  tumor;  (2)  malaria  fever;  (3) 
osteomyelitis;  (4)  gonorrhea;  (5)  autointoxication;  (6)  uric-acid  diathesis; 
and  (7)  s}^hilis  and  tuberculosis. 

Idiopathic  Intermittent  Joint  Hydrops.— This  form  of  the  disease  is 
usually  associated  with  some  disease  of  the  nervous  system,  and  is  considered 
by  Schlesinger  to  be  a  form  of  neurosis  similar  to  angioneurotic  edema.      It  has 


516 


ORTHOPEDIC  SURGERY. 


been  observed  to  occur  in  association  with  the  following  conditions:  (i)  men- 
struation; (2)  epUepsy;  (3)  hysteria;  (4)  exophthalmic  goiter;  (5)  progres- 
sive general  paralysis;  (6)  nervous  diarrhea;  (7)  pseudo-croup;  (8)  pro- 
gressive asthma;  and  (9)  it  is  closely  related  to  the  acute  circumscribed  edema 
of  Quincke. 

Schlesinger  reported  fifty-five  cases  of  intermittent  joint  hydrops.  Of 
these,  forty-one  were  of  the  idiopathic  variety.  Of  these  fifty-five  cases,  the 
location  of  the  disease  is  noted  in  forty-nine  cases.  The  following  table  (Blood- 
good)  shows  his  classification: 

MALES. 
Idiopathic. 

Up  to  10  years  of  age, o 


30 
40     " 

SO     " 
60     " 
Not  given, 4 


FEMALES. 
Idiopathic. 

Up  to  10  years  of  age, i 

7 


Symptoms. 

Total. 

Per  cent 

0 

0 

0 

I 

s 

26 

2 

5 

26 

30 
40 

50 
60 


26 


Per  cent. 

4 
33 
46 


Not  given, i 


Symptoms. — There  is  either  a  history  of  some  condition  near  the  afi'ected 
joint  producing  a  secondary  synovitis  or  the  condition  is  associated  with  some 
nervous  lesion.  The  onset  is  sudden;  the  condition  lasts  for  several  days  and 
disappears  suddenly.  It  appears  again  at  regular  and  irregular  intervals. 
Locally  there  is  swelling  of  the  affected  joint  which  may  be  due  to  efi'usion  or 
extra-articular  edema.  There  is  no  evidence  of  local  inflammation  or  increased 
surface  temperature.  There  may  be  associated  with  the  condition  swelling  of 
the  skin  of  the  thigh  or  face.  The  condition  disappears  in  several  days, 
leaving  the  joint  normal.  If  the  acute  attacks  are  frequent,  slight  swelling 
may  continually  be  present. 

Diagnosis. — This  rests  upon  the  associated  history,  the  sudden  onset  of  a 
painless,  non-inflammatory  swelling  lasting  several  days,  which  disappears 
suddenly  and  is  not  followed  by  any  permanent  joint  changes. 


NON-TUBERCULOUS  JOINT  DISEASES.  517 

Treatment. — The  treatment  of  the  symptomatic  form  consists  in  treating 
the  cause  of  the  effusion.  In  the  idiopathic  variety  favorable  results  have  not 
always  followed  the  most  careful  treatment.  Arsenic  may  be  used  to  advantage. 
Locally  during  the  attack  the  conservative  treatment  consists  in  rest,  ice,  heat, 
and  compression.  If  marked  tension  is  produced,  it  may  be  relieved  by  aspira- 
tion. Arthrotomy  and  irrigation  are  never  justifiable.  After  aspiration  the 
reaccumulation  may  in  some  degree  be  prevented  by  compression.  In  some 
cases  the  disease  disappears  suddenly  and  does  not  recur. 

-Infectious  Osteomyelitis. 

Infectious  osteomyelitis  is  an  acute  suppurative  inflammation  of  the 
shafts  and  epiphyses  of  the  bone,  the  result  of  infection  of  the  medulla  by 
pyogenic  germs.  The  process  is  essentially  similar  to  furuncle  of  the  soft 
parts,  hence  the  pseudonym  "bone  furunculosis."  The  involvement  of  the 
epiphysis  secondarily,  or  in  rare  instances  primarily,  with  extension  into  the 
joint  makes  this  disease  interesting  to  the  orthopedic  surgeon. 

Etiology. — The  most  frequent  cause  of  infection  is  Staphylococcus 
pyogenes  aureus,  although  the  Streptococcus  pyogenes,  the  pneumococcus,  and 
typhoid  bacteria  are  sometimes  found.  The  bones  most  frequently  attacked 
are  the  femur,  tibia,  and  humerus.  Infectious  osteomyelitis  is  therefore  not 
a  specific  disease,  but  one  which  may  be  produced  by  a  variety  of  pyogenic 
micro-organisms  or  by  a  combination  of  these. 

The  disease  is  most  common  in  early  life  or  chUdhood,  being  an  involve- 
ment of  bones  which  have  not  been  completely  developed,  but  it  is  occasion- 
ally met  in  advanced  life.  Boys  are  affected  three  times  as  frequently  as  girls. 
As  predisposing  causes  exposure  to  wet  and  cold,  injuries  to  the  bones,  and 
compound  fractures  may  be  cited,  and  the  condition  may  also  be  a  sequella  of 
some  infectious  disease,  as  t3qDhoid  fever,  scarlet  fever,  smallpox,  measles,  or 
pneumonia.  Or  it  may  be  secondary  to  affections  of  other  parts,  as  parony- 
chia, furuncle,  or  chronic  ulcer. 

Pathology. — The  pathology  of  this  affection  has  been  carefully  recorded 
by  Nichols,  Lannelongue,  Lexer,  and  others.  The  primary  infection  is  always 
in  the  medulla,  the  disease  beginning  usually  in  the  shaft  of  the  long  bones, 
very  rarely  in  the  epiphysis.  The  cortex  and  bony  trabeculas  are  secondarily 
destroyed.  The  process  is  active  and  abscesses  quickly  appear.  Necrosis 
occurs,  and  in  the  later  stages  the  solution  and  destruction  of  the  bone  tissue 
is  very  extensive.     The  inflammatory  process  extends  beneath  the  periosteum, 


518  ORTHOPEDIC  SURGERY. 

forming  a  subperiosteal  abscess,  the  periosteum  is  stripped  from  the  bone, 
and  the  infection  spreads  to  the  surrounding  structures,  producing  myosites 
and  necroses.  When  the  disease  originates  primarily  in  the  epiphysis,  or 
extends  secondarily  to  it,  the  bone  cavity  soon  becomes  involved  from  extension, 
and  synovitis,  simple  or  purulent,  results.  The  epiphyseal  line  may  be 
destroyed,  and  separation  of  the  epiphysis,  or  spontaneous  fracture,  may  result. 

Symptoms. — The  onset  is  sudden,  with  local  throbbing  pain.  INIotion 
is  not  at  first  interfered  with,  but  the  bone  is  sensitive  upon  pressure.  Swelling 
is  marked  over  the  area  of  infection  and  the  part  pits  upon  pressure.  The 
temperature  rises  and  the  pulse  is  accelerated.  The  tongue  is  dry  and  the  face 
flushed  and  anxious.  Leukocytosis  is  present.  Abscesses  form  in  the  super- 
ficial structures  and  their  rupture  or  release  by  incision  is  followed  by  sinuses. 

Diagnosis. — This  disease  must  be  distinguished  from  acute  articular 
rheumatism,  arthritis  deformans  sj'philitica,  tuberculosis  of  the  joints,  and 
typhoid  fever. 

It  can  readily  be  distinguished  from  articular  rheumatism  by  the  fact  that 
it  affects  only  a  single  joint,  and  by  the  rapidity  with  which  it  develops,  together 
with  the  grave  symptoms  which  accompany  it,  and  particularly  by  the  occur- 
rence of  suppuration.  From  gonorrheal  rheumatism  the  differential  diag- 
nosis is  more  difficult,  since  this  lesion  is  often  monarticular,  but  the  previous 
history  of  the  individual  and  the  absence  of  suppuration  would  be  of  value  in 
distinguishing  the  affection.  In  arthritis  deformans  syphilitica  when  the  dis- 
ease is  acute  the  resemblance  to  acute  osteomyelitis  is  very  strong,  especially 
if  suppuration  occurs.  The  presence  of  lesions  in  other  parts  of  the  body,  the 
deformity  of  the  shaft  of  the  bone  from  bending,  and  the  localized  character 
of  the  periosteitis  in  this  disease  would  render  the  diagnosis  less  difficult- 
Tuberculosis  of  the  joints  would  resemble  osteomyelitis  if  the  latter  disease  began 
in  the  epiphysis,  but  the  rapid  course  of  the  disease,  the  absence  of  tuberculous 
diathesis,  and  the  acute  and  grave  character  of  the  S)Tnptoms  would  serve  to 
differentiate  the  two  affections.  Osteomyelitis  should  also  be  distinguished 
from  typhoid  fever.  In  this  instance  the  severe  character  of  the  local  symp- 
toms, the  high  leukocytosis,  and  the  failure  to  detect  the  Widal  reaction  would 
render  the  diagnosis  sufficiently  clear. 

Prognosis. — In  the  severe  forms  of  osteomyelitis  the  prognosis  is  ver\- 
grave,  and  it  wUl  depend  upon  the  early  and  radical  measures  undertaken  to 
prevent  the  spread  of  the  infection.  It  is  frequently  followed  by  separation 
of  the  epiphysis,  and  ankylosis  is  not  uncommon  when  joint  involvement  occurs. 


NON-TUBERCULOUS  JOINT  DISEASES.  519 

Treatment. — The  treatment  consists  in  early  incision  and  drainage  of 
the  infected  area.  The  incision  should  be  free  and  the  cortex  of  the  bone 
should  be  trephined.  Curettage  of  the  deep  structures  is  not  recommended  by 
Nichols,  since  it  interferes  with  bone  regeneration. 

The  acute  symptoms  will  be  abated  by  the  incision  and  drainage,  and 
subsequently,  usually  in  about  eight  weeks,  the  necrotic  bone  will  require 
removal.  The  time  for  this  operation  should  be  carefully  determined,  and  should 
be  during  the  stage  when  marked  ossification  has  begun  in  the  deeper  layers 
of  the  periosteum,  but  is  not  far  advanced.  The  best  operation  will  be  found 
to  be  that  of  Nichols.  This  consists  in  exposing  the  necrotic  area  through  a 
long  incision,  stripping  the  periosteum  from  the  necrotic  shaft,  care  being  taken 
not  to  puncture  the  periosteum  but  to  retain  it  as  a  periosteal  tube  in  as  perfect 
condition  as  possible.  The  necrotic  shaft  is  removed  with  lion-jawed  forceps, 
section  by  means  of  a  saw  sometimes  being  necessary.  The  infiltrated  area  is 
disinfected  with  95  per  cent,  carbolic  acid  for  two  or  three  minutes  and  is  neu- 
tralized with  alcohol.  The  periosteum  is  then  folded  in  and  approximated 
with  sutures.  The  hemorrhage  is  severe  and  may  be  controlled  by  an  Esniarch 
bandage,  or  the  operation  may  be  divided  into  two  or  more  stages.  Since  the 
operation  cannot  be  perfectly  aseptic,  drainage  should  be  established.  Con- 
siderable reaction  follows  the  operation. 

Joint  involvement  should  be  treated  in  the  same  manner  as  acute  septic 
arthritis,  which  will  be  found  in  another  section.  The  deformities  following 
infectious  osteomyelitis  should  be  treated  the  same  as  those  which  follow  tuber- 
culous joint  disease. 

Traumatic  Arthritis. 

Under  the  term  traumatic  arthritis  should  be  classified  those  changes 
in  the  joint  structures  which  occur  without  a  fracture  or  dislocation 
taking  place.  These  changes  are  so  many  and  at  first  so  often  not  recog- 
nized that  in  time  they  may  lead  to  permanent  disability.  The  classification 
of  these  lesions  as  given  by  Bloodgood  is  as  follows:  {a)  An  e\-udate  with 
or  without  hemorrhage;  this  may  take  place  into  the  joint  cavity  alone  (an 
effusion)  or  into  the  tissue  without  the  synovial  membrane;  (6)  rupture  of  the 
capsule  of  the  joint;  (c)  rupture  of  one  or  more  auxiliary  ligaments;  {d)  com- 
plete or  incomplete  dislocation  or  tear  of  the  intra-articular  cartilage  (as  the 
semilunar  of  the  knee-joint);  (e)  complete  or  incomplete  separation  of  the 
articular  cartilage;     (/)  slight   incomplete  fissured   fractures   of  the   articular 


520  ORTHOPEDIC  SURGERY. 

ends  of  the  bone;  {g)  tear-fractures  of  small  bony  prominences  near  the  joint, 
with  or  without  their  dislocation  between  the  joint  surfaces. 

Pathology. — Following  the  injury  there  occurs  considerable  stretching 
and  in  most  cases  tearing  of  the  synovial  membrane  and  ligaments  about 
the  joint,  this  being  accompanied  by  marked  effusion,  which  may  be  limited 
to  the  joint  cavity,  but  generally  involves  the  extra-articular  structures  as  well 
and  contains  varying  amounts  of  hemorrhage.  When  this  effusion  is  limited 
to  the  intra-articular  structures,  it  is  readily  recognized  by  the  characteristic 
signs  of  joint  effusion,  and  when  it  invades  the  extra-articular  structures  it 
is  characterized  by  edema  of  the  surrounding  structures.  Examination  of  the 
synovial  membrane  shows  marked  edema  with  the  surface  glossy,  in  which 
may  be  numerous  areas  of  ecchymoses,  and  in  places  the  surface  of  the  mem- 
brane and  the  effusion  contain  fibrin. 

Symptoms  .^As  a  result  of  the  injury  there  follow  a  number  of  symp- 
toms which,  if  careful  attention  is  paid,  will  materially  aid  in  the  recognition 
of  the  condition.  A  marked  effusion  takes  place  which  is  readily  recognized 
by  the  obliteration  of  the  normal  contour  of  the  joint  surfaces,  by  the  fluctua- 
tion, and  by  the  position  assumed  to  allow  for  the  complete  distention  of  the 
capsule.  This  is  shown  at  the  knee  by  flexion,  at  the  hip  by  abduction,  flexion, 
and  outward  rotation.  This  effusion  is  soon  masked  by  the  extra-articular 
edema  which  rapidly  takes  place.  Hemorrhage  taking  place  into  the  effusion 
is  shown  by  superficial  ecchymosis  within  forty-eight  hours,  and  is  generally  a 
sign  of  rather  severe  injury.  Marked  tenderness  will  be  present  over  the  site 
of  the  lesion,  and  very  often  it  may  be  possible  to  recognize  a  rupture  of 
the  joint  capsule,  surrounding  ligaments,  and  tendons  by  increased  joint 
mobility  or  by  the  presence  of  an  abnormal  depression.  An  example  of  the 
increased  mobility  is  shown  in  rupture  of  the  lateral  ligaments  of  the  elbow-joint 
or  knee-joint.  As  the  exudate  is  absorbed  distinct  depressions  may  per- 
sist, and  the  diagnosis  may  be  made  on  this  symptom  alone,  as  is  seen  in  par- 
tial or  complete  rupture  of  the  tendon  of  the  quadriceps  femoris  or  in  the  lateral 
expansions  of  this  tendon.  Persistent  local  tenderness  at  the  epiphysis  gen- 
erally means  an  intra-articular  fracture  or  the  tearing  off  of  a  small  spicule  of 
bone.  In  cases  that  do  not  recover  rapidly  under  appropriate  treatment  or 
when  not  treated  there  is  persistent  disability  and  weakness  of  the  joint  struc- 
tures. 

Diagnosis. — The  recognition  of  the  condition  depends  upon  the  history 
of  trauma  which  did  not  cause  an  evident  fracture  or  dislocation,  the  local 


NON-TUBERCULOUS  JOINT  DISEASES.  521 

signs  of  intra-articular  and  extra-articular  exudate,  the  local  tenderness, 
increased  mobility,  the  detection  of  a  depression  or  pit  on  palpation,  the 
persistent  joint  weakness,  and  the  negative  results  of  the  :x:-ray  photograph. 

Treatment. — If  the  effusion  is  slight  and  the  lesion  is  evidently  mild,  imme- 
diate application  of  a  pressure  bandage  w'A\  limit  an  increase  in  the  exudate. 
This  also  gives  the  part  a  rest  and  assists  the  circulation  to  reabsorb  in  the  exu- 
date. If  the  effusion  is  excessive,  aspiration  of  the  joint  is  indicated  not  only 
to  relieve  the  acute  local  symptoms  which  often  attend  the  condition,  but  it  also 
relieves  the  distended  capsule  of  considerable  pressure,  prevents  overdisten- 
tion,  and  at  the  same  time  affords  an  opportunity  for  a  bacteriologic  exami- 
nation of  the  exudate.  If  the  fluid  reaccumulates,  repeated  aspiration  may 
be  used;  and  if  the  examination  of  the  exudate  shows  a  pyogenic  infection, 
early  arthrotomy,  irrigation,  and  drainage  will  give,  in  most  cases,  a  useful  joint. 

After  the  acute  symp'oms  have  subsided,  in  addition  to  rest  and  a  pressure 
bandage,  hot  air  and  massage  once  or  twice  daily  will  materially  aid  in  a  return 
of  the  joint  structures  to  normal.  After  one  week,  in  mild  cases,  the  patient 
should  be  given  passive  motion  and  encouraged  to  use  the  part.  When  pain 
and  loss  of  function  persist,  it  is  evident  that  a  more  severe  condition  exists,  such 
as  a  lacerated  joint  capsule  or  tendon,  an  injury  of  the  cartilage,  or  an  intra- 
articular fracture.  In  these  cases  the  relaxation  of  the  tendons  and  joint  struc- 
tures requires  prolonged  support  in  some  suitable  apparatus.  This  support, 
however,  should  be  vigorously  supplemented  by  hot  air,  massage,  hot  and  cold 
douches,  and  passive  motion. 

Suppurative  Arthritis. 

Suppurative  arthritis  varies  in  its  intensity  and  in  the  extent  of  involve- 
ment of  surrounding  structures  according  to  the  infecting  agent.  Certain 
micro-organisms  cause  rapid  and  complete  destruction  of  the  intra-articular 
and  extra-articular  structures,  and  in  many  cases  terminates  in  death,  while 
other  micro-organisms  may  cause  only  moderate  intra-articular  changes  and 
in  some  cases  are  only  followed  by  ankylosis.  The  most  frequent  causes  of 
suppurative  arthritis  are:  (i)  penetrating  wounds  entermg  the  joint  or  just 
external  to  its  capsule;  (2)  direct  extension  from  a  focus  of  acute  suppurative 
osteomyelitis;  (3)  extension  through  the  blood  from  a  diseased  focus  else- 
where in  the  body;  (4)  as  one  of  many  lesions  of  pyemia;  (5)  extension  by  the 
lymphatic  system  from  an  infected  wound  at  some  distance  from  the  joint;  (6) 
direct  extension  from  an  infected  wound  near  the  joint. 


522  ORTHOPEDIC  SURGERY. 

Pathology. — The  changes  which  take  place  in  suppurative  arthritis  are 
in  most  cases  rapid.  As  a  rule,  when  the  infecting  agent  is  a  pyogenic  organism, 
in  the  first  few  hours  the  condition  consists  of  some  effusion  which  is  serous  or 
sero-fibrinous.  At  the  same  time  the  synovial  membrane  will  show  the  pres- 
ence of  the  infecting  organism  surrounded  by  the  products  of  inflammation. 
The  effusion  rapidly  becomes  purulent,  contains  many  leukocytes  in  all  stages 
of  degeneration,  and  in  some  cases  a  slight  amount  of  blood.  Numerous 
organisms  can  be  demonstrated  throughout  the  fluid  and  synovial  membrane. 
The  latter  becomes  edematous  and  rapidly  undergoes  various  stages  of  degen- 
eration. The  inflammation  may  be  confined  to  the  intra-articular  structures 
and  subsynovial  tissues,  with  consequent  marked  peri-articular  edema,  or 
extension  may  take  place,  rupture  of  the  synovial  membrane  may  occur,  and 
the  inflammatory  process  may  attack  the  cartilages,  bones,  tendons,  bursae, 
and  muscles  about  the  joint,  and  abscesses  result  which  in  turn  cause  extensive 
destruction  to  all  the  soft  parts. 

When  the  arthritis  is  secondary  to  an  acute  suppurative  osteomyelitis,  the 
joint  symptoms  often  mask  the  bone  inflammation,  and  the  latter  condition 
is  very  often  not  recognized.  The  infecting  organisms  most  frequently  found 
in  suppurative  arthritis  are  the  streptococcus,  the  Staphylococcus  albus  and 
aureus,  the  pneumococcus,  the  t3qDhoid  bacillus,  the  Bacillus  aerogenes  cap- 
sulatus,  and  the  gonococcus. 

Suppurative  arthritis  following  pneumonia  is  very  rare.  Wliile  there  is 
frequently  noted  a  joint  effusion  as  a  sequel  to  pneumonia,  it  is  in  most  instances 
sterile.  While  some  cases  have  been  reported  as  occurring  independently  of 
pneumonia,  it  is  doubted  very  much  whether  a  careful  inquiry  would  not  have 
established  a  history  of  pneumonia.  Most  cases  in  which  the  joint  is  infected 
by  the  pneumococcus  are  the  subject  of  a  general  septicemia.  Herrick  gives 
the  mortality  as  65  per  cent.,  based  upon  a  study  of  fifty-two  reported  cases. 
In  most  cases  the  infection  is  polyarticular.  The  arthritis  is  often  seen  in  asso- 
ciation with  a  pneumococcus  meningitis. 

Suppurative  arthritis  following  typhoid  fever  is  at  times  rather  severe, 
while  in  other  instances  the  infection  seems  to  be  mUd.  The  arthritis  may  be 
a  primary  infection,  but  in  most  cases  is  due  to  a  neighboring  focus  in  the  epi- 
physis. This  form  of  purulent  arthritis  may  not  be  virulent,  or  the  joint  may 
recover  after  conservative  treatment,  while  at  times  it  may  be  very  extensive 
and  destructive  and  lead  to  spontaneous  dislocations,  as  shown  by  Keen's  series 
of  84  cases,  in  which  spontaneous  dislocation  occurred  in  40  per  cent,  of  the 


NON -TUBERCULOUS  JOINT  DISEASES.  523 

cases.  Whitman  reports  a  case  in  whicli  there  was  destructive  arthritis  of 
one  hip-joint,  spontaneous  displacement  of  the  femur  on  the  other  side,  and 
secondary  contractures  of  the  knee-joint  and  ankle-joint. 

Symptoms. — The  onset  of  the  suppurative  arthritis  may  be  sudden  or 
gradual,  according  to  the  infecting  agent.  The  symptoms  may  come  on  after 
recovering  from  an  attack  of  pneumonia,  typhoid  fever,  or  other  acute  infec- 
tious disease.  At  first  there  may  be  a  chill,  followed  by  fever,  which  continues 
high;  the  local  joint  symptoms  may  be  those  of  a  simple  synovitis  for  twenty- 
four  to  forty-eight  hours.  After  this  time,  as  the  swelling  increases,  there 
is  marked  redness,  peri-articular  edema,  local  tenderness,  muscular  spasm, 
deformity,  lymphangitis,  and  adenitis.  The  temperature  at  first  is  continually 
elevated,  but  after  a  time  it  may  drop  to  normal  in  the  morning  and  be  elevated  in 
the  evening.  Constitutional  symptoms  of  infection  may  occur,  while  the  local 
inflammatory  signs,  unless  relieved  by  operation,  steadily  progress  until  retro- 
grade changes  take  place,  rupture  occurs,  or  death  results  from  septicemia. 

Diagnosis. — This  depends  upon  the  history  of  an  acute  infectious  disease, 
trauma,  a  local  septic  process,  or  some  primary  focus  of  infection,  combined 
with  the  local  signs  of  suppuration,  the  general  constitutional  disturbance,  the 
high  leukocytosis,  and  the  results  of  an  examination  of  the  effusion  obtained 
by  aspiration. 

Treatment. — If  in  doubt  as  to  the  character  of  the  effusion,  better  func- 
tional results  will  be  obtained,  convalescence  shortened,  the  mortality  decreased, 
and  the  secondary  deformities  prevented  by  thorough,  efficient,  operative  treat- 
ment dependent  upon  the  results  of  an  examination  of  the  aspirated  fluid.  If 
the  fluid  is  found  to  be  sterile,  the  treatment  should  be  conservative.  This 
should  consist  of  rest  and  immobilization  for  a  few  days,  and  later  these  should 
be  supplemented  by  massage,  evaporating  lotions,  the  application  of  heat  and 
cold,  and  the  institution  of  passive  motion.  Later,  efforts  should  be  made  to 
prevent  any  deformity  by  means  of  appropriate  apparatus. 

When  the  aspirated  fluid  is  found  to  contain  pyogenic  organisms,  the 
affected  joint  should  be  thorouglily  opened,  irrigated,  and  efficient  drainage 
established.  If  the  infection  is  a  mild  one,  drainage  should  be  obtained  by 
a  strip  of  protective  or  rubber  dam,  as  drainage-tubes  and  gauze  are  liable  to 
increase  the  inflammatory  condition  of  the  synovial  membrane.  The  arthrot- 
omy  may  be  performed  under  local  anesthesia  when  the  pneumococcus  is  the 
infecting  agent,  on  account  of  the  effect  a  general  anesthetic  would  have  upon 
the  convalescent  lung.     If  the  infection  is  a  severe  one,  general  anesthesia  should 


524  ORTHOPEDIC  SURGERY. 

be  used,  the  incisions  should  be  large,  and  it  is  often  well  to  obtain  postural 
drainage  through  the  popliteal  space.  In  many  cases  the  arthritis  is  secondary 
to  a  bony  focus.  This  is  especially  true  in  cases  of  acute  epiphysitis  in  children, 
in  typhoid  infection,  and  occasionally  in  pneumococcus  infection.  It  is  ex- 
tremely rare  in  gonorrheal  infection.  When  operating,  the  bones  entering  into 
the  formation  of  the  joint  should  be  carefully  explored  and  any  focus  present 
should  be  thoroughly  excised.  When  extra-articular  abscesses  form,  they 
require  multiple  incisions  for  drainage.  In  some  cases  the  general  condition 
may  be  so  bad  and  the  infection  so  severe  that  amputation  will  offer  the  only 
means  of  saving  the  patient's  life.  The  treatment  of  the  deformities  which 
are  apt  to  occur  as  a  result  of  the  arthritis  wUl  be  discussed  under  contractures 
and  ankylosis. 

Acute  Suppurative  Arthritis  of  Infancy. 

Very  often  there  is  seen  in  infants  an  acute  suppurative  arthritis  which  is 
due  to  an  extension  of  an  acute  epiphysitis  involving  the  joint.  In  many  cases 
the  source  of  infection  is  not  apparent,  it  often  occurring  without  any  other 
demonstrable  focus.  It  may  foUow  the  acute  exanthemata,  and  in  some  cases 
is  due  to  a  gonococcus  infection.  In  most  cases,  however,  the  infecting  agent 
is  the  Staphylococcus  aureus  or  albus  and  the  streptococcus.  It  may  be  a  non- 
articular  or  a  polyarticular  infection,  the  former  being  more  frequent.  The 
hip-joint  and  the  knee-joint  are  most  frequently  aft'ected. 

Symptoms. — The  onset  in  most  cases  is  gradual.  The  patient  begins  to 
complain  of  lameness  and  pain  on  motion  at  the  affected  joint.  This  is  followed 
by  localized  swelling,  at  first  limited  to  the  epiphysis,  but  later  involving  the 
entire  joint.  The  appearance  of  the  joint  resembles  very  much  tuberculous 
disease  except  that  there  is  more  severe  pain,  some  redness  of  the  skin, 
marked  tenderness,  and  greater  constitutional  disturbance.  The  course  of  the 
disease  is  more  rapid  than  tuberculous  disease.  In  a  few  cases  the  onset  is 
sudden,  the  course  rapid,  and  marked  constitutional  disturbances  are  present. 
If  the  process  is  ahowed  to  continue,  the  entire  joint  may  become  disorganized, 
the  epiph)'ses  destroyed,  subluxations  occur,  and  peri-articular  abscesses  result. 

Diagnosis. — This  depends  upon  the  rapidity  of  the  joint  symptoms,  the 
marked  constitutional  disturbances,  the  leukocytosis,  and  the  results  of  exami- 
nation of  the  aspirated  fluid. 

Treatment. — As  in  all  forms  of  supposed  suppurative  arthritis,  early 
incision  is  indicated      If  the  effusion  contains  pyogenic  organisms,  the  joint 


NON-TUBERCULOUS  JOINT  DISEASES.  525 

should  be  thoroughly  opened,  osseous  foci  excised,  the  joint  thoroughly  irri- 
gated and  efficiently  drained.  During  the  course  of  treatment  suitable  appa- 
ratus should  be  used,  not  only  to  hold  the  parts  at  rest,  but  to  prevent  sub- 
luxations and  ankylosis  in  a  deformed  position.  In  some  cases  the  disease  may 
have  extended  to  the  shaft  of  the  bone,  in  which  case  it  is  advisable  to  remove 
the  diseased  epiphysis. 

The  Ultimate  Results  of  Acute  Suppurative  Arthritis  in  Infancy. — In 
most  cases  the  disease  has  extended  so  far  and  the  epiphysis  is  so  far  diseased 
or  destroyed  that  marked  deformity  results  in  after-life.  In  involvement  of 
the  hip-joint  the  destructive  process  is  so  extensive  in  some  cases  that  the  result 
in  after-life  resembles  congenital  dislocation.  Hoffmann  gives  a  mortality 
rate  of  46  per  cent.,  based  on  a  study  of  122  cases. 

Syphilitic  Joint  Disease. 

The  recognition  of  chronic  joint  lesions  as  a  manifestation  of  hereditary 
and  acquired  syphilitic  infection  is  becoming  more  frequent,  especially  as  the 
exact  joint  lesions  of  various  diseases  are  becoming  better  understood.  Pre- 
vious to  the  discovery  of  the  part  played  by  the  tubercle  bacUli  in  chronic  joint 
diseases  many  cases  that  were  undoubtedly  tubercular  were  looked  upon  as 
being  due  to  s3qDhLlis.  Since  Koch's  discovery,  however,  the  comparatively 
infrequent  diagnosis  of  syphilitic  joint  disease  leads  one  to  believe  that  errors 
were  made  in  the  other  extreme  and  many  cases  were  classified  as  tuberculous 
which  could  possibly  have  been  traced  to  hereditary  or  acquired  syphilis.  Some 
surgeons  went  so  far  as  to  claim  that  there  was  no  such  lesion  as  syphUitic  joint 
disease,  as  Ridlon  states,  commenting  on  the  criticism  given  his  paper  on 
"Syphilitic  Joint-disease  in  Children,"  which  was  read  in  1886  before  the  Sec- 
tion on  Orthopedic  Surgery  of  the  New  York  Academy  of  Medicine.  Since  then 
the  subject  has  received  considerable  attention  and  the  recognition  of  syphilitic 
joint  lesions  is  very  common. 

Etiology, — S}TDhLlitic  joint  disease  may  be  due  to  inherited  or  acquired 
S3^hLlis.  Inherited  syphilis  may  be  transmitted  from  one  or  both  parents, 
and  in  some  cases  may  be  transmitted  from  a  grandparent,  the  parents  having 
shown  no  evidence  of  the  disease. 

Inherited  syphilis.  Syphilitic  joint  disease  afl'ects  the  knee-joint  more 
frequently  than  other  joints;  in  many  cases  there  is  multiple  epiphyseal  involve- 
ment and  the  affection  may  be  bUateral.  It  is  more  frequently  complicated 
by  arthritic   symptoms  than   the   acquired   form.     Giiterbock  considers  that 


526  ORTHOPEDIC  SURGERY. 

joint  lesions  occur  in  one  case  in  three  hundred  of  inherited  s\^hilis  under  five 
years  of  age.  There  may  be  two  forms  of  inherited  s)'philitic  joint  disease: 
(i)  the  early  variety,  in  which  the  lesion  essentially  involves  the  epiphyseal 
cartilage,  kno-wn  as  the  osteochondritis  of  Parrot;  and  (2)  the  late  variety, 
in  which  the  periosteum  is  chiefly  involved,  termed  osteoperiosteitis. 

Pathology. — Hereditary  syphilis:  The  form  seen  in  early  childhood, 
and  kno^^-n  as  osteochondritis,  is  characterized  by  alterations  occurring  at  the 
junction  of  the  epiphysis  with  the  diaphysis  of  the  long  bones.  A  longitudinal 
section  made  through  these  parts  shows  the  line  of  junction  as  a  bluish-white 
or  yellowish-white  irregular  zone  about  2  or  3  mm.  in  thickness.  As  the  con- 
dition advances  this  line  becomes  thicker  and  more  yellow.  The  microscopic 
changes  consist  in  an  irregular  proliferation  of  the  cartilage  cells,  premature 
calcification,  a  poor  blood-supply  and  consequent  fatty  degeneration.  As  this 
necrosis  occurs  the  area  is  surrounded  by  inflammatory  tissue  which  is  partlv 
the  cause  of  the  increased  thickness.  As  this  necrosis  continues  suppuration 
may  occur,  and  as  a  final  result  complete  separation  of  the  epiphysis  may  take 
place,  so  that  future  growth  is  prevented.  The  neighboring  joint  is  sooner  or 
later  the  seat  of  an  arthritis  which  may  be  serous'  or  purulent.  Some  cases  are 
characterized  by  ultimate  destruction  of  the  cartilage. 

In  the  late  form  of  hereditary  s}qDhilis  there  occurs  an  osteoperiosteitis  in 
the  bones  near  the  joint.  It  is  characterized  by  a  gummatous,  infiltrating  over- 
growth of  the  epiphysis,  which  produces  a  spindle-shaped  swelling  and  resembles 
in  some  degree  the  tumor  albus  of  tuberculous  knee-joint  disease.  The  knee 
is  the  usual  seat  of  the  disease.  The  joint  is  generally  involved,  there  being  an 
increased  amount  of  fluid  in  the  joints  with  marked  hA'pertrophy  of  the  svmovial 
membrane.     Several  joints  may  be  aft'ected  simultaneously. 

Acquired  syphilis:  The  pathologic  changes  in  syphilitic  joints  may  occur 
in  two  forms:  a  primary  infection  of  the  sjmovial  membrane,  and  a  secondary 
infection  due  to  the  extension  of  an  osteonrv'elitis.  "\\Tien  primary  infection 
takes  place,  there  results  hypertrophy  of  the  synovial  membrane,  and  marked 
enlargement  of  the  villi  occurs.  Gummatous  formation  may  be  single  or 
multiple.  Necrosis  and  resultant  disorganization  of  the  intra-articular  struc- 
tures or  suppuration  never  takes  place.  Fibrous  ankylosis  is  liable  to  occur 
on  account  of  the  mflammatory  changes  caused  by  the  gummata,  and  the  result- 
ing scar  formation  which  takes  place  in  healing  under  treatment.  WTien  the 
arthritis  is  secondary  to  an  osteomyelitis,  h^-pertrophy  of  the  synovial  membrane 
and  villi  occurs,  and  gummatous  formation  may  be  single  or  multiple,  or  may 


NON-TUBERCULOUS  JOINT  DISEASES.  527 

be  pedunculated  and  form  intra-articular  free  bodies.  Marked  disorganization 
of  the  cartilage  may  occur,  which  process  begins  in  the  center  and  extends  to 
the  periphery.     The  gummata  are  firm,  reddish-gray,  and  irregular  in  character. 

Gummatous  formation  in  the  shaft  of  the  bones  appears  as  an  osteo-peri- 
osteitis,  and  is  characterized  by  the  formation  of  a  smooth,  fluctuating  swelling 
beneath  the  periosteum.  The  spongy  structure  of  the  bone  may  also  be  the 
seat  of  gummata.  The  fluid  is  cloudy  and  contains  but  very  few  cells.  Later 
fatty  degeneration  and  absorption  take'  place  with  the  formation  of  scar  tissue 
and  permanent  thickening  of  the  bone. 

Symptoms. — In  hereditary  syphilis  there  is  marked  enlargement  of  one 
or  several  epiphyses,  generally  followed  by  involvement  of  the  joint.  ^Moderate 
muscular  spasm  and  atrophy  may  occur.  The  subjective  symptoms  are  slight. 
In  the  convalescent  stage  limitation  of  motion  or  complete  ankylosis  may  result. 
There  are  generally  other  signs  of  hereditary  syphilis  present.  In  some  cases 
there  may  be  violent  symptoms  suggesting  suppurative  arthritis. 

In  acquired  syphUis  the  onset  of  the  arthritis  is  rarely  acute,  and  generally 
occurs  in  the  secondary  stage  of  the  disease.  Syphilitic  involvement  of  a  joint 
is  sometimes  seen  in  the  tertiary  stage.  The  knee  is  the  usual  joint  affected. 
It  may  be  bilateral  or  other  joints  may  be  involved  with  the  knee.  The  physical 
signs  are  concomitant  with  the  sj'philitic  rash,  and  consist  of  severe  pain,  ten- 
derness, and  gradual  swelling  at  the  involved  joint.  The  pain  is  generally  more 
intense  at  night.  There  may  be  a  tendency  to  contraction  in  either  flexion 
or  abduction.  The  affection  is  very  rarely  acute,  except  when  suppuration 
occurs.     Functional  disturbance  is  usually  very  slight. 

Diagnosis. — There  is  generally  in  the  hereditary  form,  and  always  in  the 
acquired  form,  a  history  of  syphilitic  infection  or  signs  of  the  disease  elsewhere. 
In  the  hereditary  form  the  disease  appears  either  in  the  first  few  months  or  as 
a  late  form  from  the  fifteenth  to  the  eighteenth  year.  The  epiphyseal  enlarge- 
ments are  generally  painless  and  are  distinguished  from  those  of  rachitis  by 
their  irregular  distribution,  by  the  age  of  the  patient,  and  by  the  presence  of 
other  syphilitic  symptoms. 

The  acquired  form  is  recognized  by  the  history  of  syphilitic  infection,  other 
signs  of  the  disease,  by  its  appearance  about  the  time  of  the  appearance  of  the 
rash,  by  the  marked  tenderness,  and  by  the  pain,  which  is  greater  at  night.  The 
condition  may  be  confused  with  tuberculous  joint  disease,  especially  if  only 
one  joint  is  involved.  In  the  latter  there  may  be  a  history  of  syphilitic  infection, 
which  makes  the  diagnosis  more  difficult.     A  negative  tuberculin  test  would 


528  ORTHOPEDIC  SURGERY. 

favor  the  diagnosis  of  syphilis.  In  syphilitic  joint  disease  marked  improx'ement 
takes  place  under  specific  treatment.  In  cases  of  extreme  doubt,  and  where  an 
absolute  diagnosis  is  required,  an  arthrotomy  may  be  performed  and  a  portion 
of  the  synovial  membrane  removed  for  histologic  study  and  animal  inoculation. 
Treatment. — In  both  hereditary  and  acquired  syphilitic  joint  infection 
the  treatment  consists  in  attention  to  the  general  health,  food,  and  medicinal 
measures.  Specific  treatment  should  be  instituted  in  both  forms  of  the  dis- 
ease. In  the  hereditary  form  mercury  and  potassium  iodid  may  be  used.  Sub- 
limate baths  (8  grains  to  the  bath)  may  be  given  to  small  children,  as  recom- 
mended by  Giiterbock.  Calomel  may  be  used  in  varying  doses.  If  the  stomach 
Avill  tolerate  large  doses,  children  may  be  given  one-thirtieth  to  one-twenty- 
fourth  of  a  grain  of  bichlorid  or  biniodid,  with  from  five  to  forty  grains  of  potas- 
sium iodid  three  to  four  times  a  day,  as  recommended  by  Ridlon.  Local  treat- 
ment should  not  be  neglected.  In  the  acquired  form  the  arthritic  symptoms 
generally  disappear  at  the  time  of  the  disappearance  of  the  rash.  If  the  joint 
symptoms  occur  in  the  secondary  stage  of  the  disease,  mercur}^  in  any  of  its 
various  forms  may  be  used.  When  they  occur  in  the  tertiary  stage  and  the 
gummata  are  large,  in  conjunction  with  medicinal  treatment  arthrotomy  and 
total  excision  of  the  gummata  will  be  followed  by  better  results  than  if  medicinal 
treatment  alone  is  used.  ]\Iechanical  measures  and  rest  in  bed  are  essential 
in  some  stages  of  the  disease.  Rest  in  bed  is  necessar}'  during  the  painful  stages 
of  the  acquired  form.  Occasionally  mechanical  apparatus  may  be  used  to 
advantage  to  give  support  to  tender  and  painful  joints  and  to  prevent  deformity, 
which  in  a  small  proportion  of  cases  is  liable  to  occur. 

Gonorrheal  Arthritis. 

Gonorrheal  infection  of  joints  complicating  cases  of  gonorrheal  urethritis 
generally  occurs  during  the  late  stage  of  an  acute  attack.  It  rarely  occurs 
before  the  third  week ;  it  may  occur  during  a  very  chronic  attack  and  may  com- 
plicate either  a  gonorrheal  urethritis  or  follow  ophthalmia  neonatorum,  as  shown 
by  the  cases  reviewed  by  Hawthorne.  Moderate  injury  to  some  joint  occurring 
during  the  late  stage  of  gonorrhea  is  usually  the  predisposing  cause  to  the 
development  of  gonorrheal  arthritis. 

Frequency  and  Order  of  Involvement. — Gonorrheal  arthritis  frequently 
begins  as  a  polyarticular  affection.  The  statistics  of  jSIarkheim  and  those  of 
Bloodgood  showed  that  it  was  polyarticular  in  56  and  60  per  cent,  of  cases. 
Bloodgood,  however,  states  that  on  admission  to  the  hospital  more  than  one 


NON-TUBERCULOUS  JOINT  DISEASES. 


529 


joint  was  affected  in  only  ii  per  cent,  of  cases.  In  a  series  of  251  cases  reported 
by  Northrup,  56  were  monarticular,  in  20  cases  two  joints  were  involved,  and 
in  175  cases  three  or  more  joints.  Miihsam  found  30  monarticular  infections 
in  41  cases.  Julien  found  143  monarticular  infections  in  348  cases.  Mark- 
heim  reports  52  cases  in  which  the  affection  was  mon-articular  in  13,  two  joints 
were  involved  in  12,  and  in  the  other  cases  three  or  more  joints  were  involved. 

Markheim  gives  the  following  order  of  frequency  of  involvement:  knee, 
hip,  shoulder,  wrist,  and  elbow.  Bloodgood  g'ves  the  order  as  follows:  Knee, 
ankle,  wrist,  elbow,  shoulder,  and  hip. 

The  combined  statistics  of  Northrup,  Finger,  and  Bennecke,  comprising 
704  cases,  show  that  the  joints  were  involved  in  the  following  order  of  frequency: 


NOKTHRDI-. 

Finger, 

Bennecke. 

TOTAI.    i 

NORTHRTTP. 

Finger. 

Bennecke. 

Tot  At. 

Knee,  ... 

91 

136 

31 

2.8 

Temporo-maxillary, 

2 

14 

16 

Ankle,  . . . 

S7 

59 

9 

125 

Small  Joints  of  Foot, 

40 

6 

46 

Wrist,  . . . 

27 

43 

6 

76 

Heel  and  Toes 

21 

21 

Elbow,  .. 

18 

25 

ID 

53 

Small  Joints  of  Hand, 

II 

35 

4 

50 

Shoulder, 

16 

24 

4 

44 

Sterno-clavicular, 

3 

Hip,    

16 

18 

8 

42 

Other  Articulations, . 

21 

21 

Men  are  more  frequently  subject  to  gonorrheal  arthritis  than  women,  and 
about  3  to  5  per  cent,  of  all  cases  of  gonorrheal  urethritis  are  complicated  by 
joint  lesions. 

Pathology. — The  joint  lesions  of  gonorrheal  infection  may  be  classified 
under  the  following  forms: 

1.  Intra-articular  inflammation.  This  form  consists  of  an  acute 
inflammatory  process  which  involves  only  the  superficial  layers  of  the  synovial 
membrane,  in  which  the  effusion  may  be  serous,  sero-fibrinous,  hemorrhagic,  or 
purulent. 

2.  Extra-articular  inflammation.  This  form  is  characterized  by  a 
marked  inflammatory  process  occurring  in  the  peri-articular  structures.  The 
joint  infection  is  very  slight  and  in  some  cases  there  is  no  effusion  present. 
The  bursae,  tendon-sheaths,  and  ligamentous  structures  are  surrounded  by  an 
inflammatory  exudate,  which  tends  to  become  organized. 

3.  Pan- articular  inflammation.  This  variety  is  the  form  most  fre- 
quently seen,  and  is  characterized  by  an  acute  inflammatory  process  which 
involves  the  synovial  membrane  in  a  serous,  sero-fibrinous,  hemorrhagic,  or 
purulent  inflammation;  the  deep  layers  and  all  peri-articular  structures  are 
infected.     This  form  tends  to  become  chronic,  or  may  be  chronic  from  the 


530  ORTHOPEDIC  SURGERY. 

beginning,  and  finally  leads  to  varying  degrees  of  deformity,  contracture,  anky- 
losis, and  in  a  few  cases  to  entire  destruction  of  the  articular  surfaces. 

4.  Polyarticular  serous  effusion.  \Vhile  there  has  been  no  pathologic 
demonstration  of  such  a  condition,  the  repeated  observation  made  by  various 
writers  of  the  existence  of  a  primary  involvement  of  a  number  of  joints  before 
the  condition  is  well  marked  in  any  one  joint  shows  that  there  exists  a  multiple 
infection  which  is  characterized  by  several  joints  being  affected  simultaneously, 
the  symptoms  of  the  condition  being  pain,  slight  tenderness,  muscular  spasm, 
restriction  of  motion,  and  very  slight  effusion  in  the  joints,  which  may  persist 
for  several  days. 

The  pathologic  changes  are  dependent  more  or  less  upon  the  character 
of  the  effusion  present.  When  simple  serous  effusion  is  present,  the  parts  are 
very  little  altered,  and  the  condition  is  not  attended  by  any  marked  symptoms 
and  is  followed  by  a  complete  return  of  normal  function.  In  the  sero-fibrinous 
variety  there  occurs  a  hypertrophy  of  the  synovial  membrane,  accompanied  by 
a  deposit  of  fibrin  on  the  synovial  membrane  which  causes  the  folds  of  the  mem- 
brane to  adhere  to  one  another,  the  deeper  layer  of  the  membrane  and  peri- 
articular structure  are  involved,  new  blood-vessels  are  formed,  and  granulation 
tissue  becomes  abundant,  so  that  when  organization  of  the  fibrin  occurs  the 
intra-articular  and  extra-articular  structures  are  bound  together  in  a  mass  of 
adhesive  inflammation,  which  ultimately  leads  to  impairment  of  the  joint  struc- 
tures and  ankylosis.  At  times  the  serous  or  sero-fibrinous  effusion  may  be 
mLxed  with  blood,  which,  however,  has  little  influence  upon  the  ultimate  results 
of  the  inflammatory  process. 

^Vhen  the  effusion  becomes  purulent,  the  condition,  local  and  general, 
becomes  very  intense,  and  aU  the  symptoms  of  an  acute  purulent  arthritis  are 
present. 

There  is  occasionally  seen  a  variety  of  gonorrheal  arthritis  Avhich  would 
be  included  under  the  classification  of  extra-articular  inflammation.  Konig 
terms  it  phlegmonous  inflammation.  This  form  is  characterized  by  very  little 
joint  effusion,  but  in  the  peri-articular  structures  and  deep  layers  of  the  s}Tiovial 
membrane  there  is  a  very  severe  inflammatory  process  which  leads  to  disor- 
ganization of  the  joint  structures,  extra-articular  abscesses,  gonorrheal  osteo- 
myelitis, general  gonorrheal  septicemia,  ankylosis  of  the  joint,  and  in  rare  cases 
death  may  be  the  end  result. 

Presence  of  the  gonococcus.  Generally  in  the  acute  form,  and  occasionaUy 
in  the  chronic  form,  gonococci  can  be  demonstrated  in  the  joint  effusion.     They 


NON-TUBERCULOUS  JOINT  DISEASES.  531 

are  to  be  found  iii  the  phagocytes  or  in  the  epithelial  cells  as  intra-cellular  or 
extra-cellular  bodies.  Their  presence,  however,  is  more  constant  in  the  granu- 
lation tissue  of  the  synovial  membrane,  and  they  may  be  found  here  when 
repeated  examinations  of  fluid  removed  by  aspiration  faU  to  show  their  presence. 
Vaquez  and  Lanbry  report  three  cases  in  which  examination  of  the  joint  fluid 
was  negative,  yet  ankylosis  occurred,  and  the  examination  of  a  portion  of  granu- 
lation tissue  from  the  synovial  membrane  obtained  by  arthrotomy  showed  them 
to  be  present  in  great  numbers. 

The  view  held  formerly,  that  purulent  arthritis  occurring  in  a  joint  primarily 
infected  with  the  gonococcus  was  due  to  a  mixed  infection  with  other  pyogenic 
organisms,  can  no  longer  be  considered  to  be  true,  since  the  bacteriologic  studies 
made  by  H.  H.  Young  showed  conclusively  that  this  condition  was  due  to  a 
pure  culture  of  the  gonococcus. 

Ankylosis,  when  it  occurs,  is  generally  fibrous  and  rarely  bony.  When 
fibrous,  it  is  due  to  the  organization  of  the  exudate  by  a  process  similar  to  the 
formation  of  stricture  in  the  urethra.  When  bony  ankylosis  occurs,  it  generally 
follows  the  phlegmonous  or  extra-articular  form  of  disease,  in  which  the  process 
has  been  so  extensive  that  the  joint  is  soon  involved  and  marked  destruction 
of  the  epiphysis  occurs,  and  in  some  cases  a  gonorrheal  osteomyelitis,  as  recorded 
byBloodgood. 

Symptoms. — The  symptoms  of  joint  involvement  generally  occur  after 
the  third  week  of  the  onset  of  the  urethritis.  The  affection  begins  in  most 
cases  as  a  polyarticular  disease.  Most  patients  give  a  history  of  pain,  restriction 
of  motion,  tenderness,  and  slight  swelling  in  several  joints  at  the  onset.  After 
a  few  days  the  symptoms  increase  in  severity  in  one  or  several  joints,  and  the 
other  joints  entirely  recover,  and  when  first  seen  the  lesion  is  limited  to  only 
one  or  perhaps  two  joints.  The  involved  joint  is  then  very  markedly  swollen, 
reddened,  tender,  and  may  show  fluctuation.  There  is  increase  in  local  and 
general  temperature.  The  condition  in  this  stage  is  often  mistaken  for 
acute  articular  rheumatism.  If  the  effusion  is  serous,  the  local  condition  does 
not  progress  beyond  this  stage,  but  rapidly  improves  untU  the  joint  becomes 
normal.  In  most  cases,  however,  infiltration  of  the  entire  joint  structure  and 
peri-articular  tissues  takes  place,  so  that  the  soft  parts  become  very  much 
enlarged  and  edematous,  the  skin  is  red,  glazed,  and  tender,  and  the  least  move- 
ment causes  intense  pain.  Muscvilar  spasm  occurs  early  and  the  joint  assumes 
a  flexed  position.  This  stage  continues  for  a  considerable  time,  untU  reparative 
processes  set  in,  when  the  acute  symptoms  subside,  moderate  muscular  atrophy 


532  ORTHOPEDIC  SURGERY. 

results,  some  peri-articular  induration  persists,  and  ankylosis  (fibrous  generally) 
occurs  in  the  deformed  position.  If  purulent  inflammation  is  present,  consti- 
tutional symptoms  become  marked,  rupture  of  the  synovial  membrane  occurs 
with  the  formation  of  extra-articular  abscesses  which  may  ultimately  rupture 
at  the  point  of  least  resistance. 

Diagnosis. — The  condition  may  be  recognized  by  the  history  of  gon- 
orrheal urethritis,  vulvo-vaginitis,  or  ophthalmia  neonatorum,  the  possible  his- 
tory of  primary  polyarticular  involvement  followed  by  localization  of  the  process 
in  one  or  several  joints,  by  the  character  of  the  swelling,  and,  finally,  by  the 
examination  of  the  aspirated  fluid  or  portions  of  granulation  tissue  obtained 
by  arthrotomy. 

Prognosis. — In  the  acute  form  suppuration  and  in  the  chronic  form  anky- 
losis are  the  results  that  are  mostly  to  be  found.  The  usual  tendency  in  gon- 
orrheal arthritis  is  partial  or  complete  destruction  of  the  synovial  membrane, 
the  formation  of  granulation  tissue,  organization  of  the  fibrinous  products,  and 
finally,  partial  or  complete  ankylosis  with  ultimate  impairment  of  the  joint  func- 
tions. To  obtain  the  best  functional  result  it  is  necessary  to  limit  the  process 
before  extensive  destruction  of  the  synovial  membrane  has  taken  place.  Cases 
in  which  the  infection  is  limited  to  the  intra-articular  structures  and  in  which 
the  effusion  is  serous  recover  generally  with  good  functional  results.  When 
aU  the  intra-articular  and  extra-articular  structures  are  involved  and  the 
effusion  is  sero-fibrinous  or  purulent,  the  prognosis  as  to  function  is  very  poor. 

Treatment. — The  line  of  treatment  to  be  followed  in  gonorrheal  arthritis 
depends  very  much  upon  the  stage  of  the  disease,  the  extent  of  the  lesion,  and 
the  deformity  present.  In  early  cases  in  which  the  disease  is  limited  to  the 
intra-articular  structures,  is  not  extending,  and  the  symptoms  are  not  acute, 
the  treatment  consists  in  immobilization,  preferably  in  plaster-of-Paris,  in  some 
cases  combined  with  traction  and  the  local  use  of  ointments  to  assist  in  absorb- 
ing the  effusion.  Ichthyol  ointment  (40  to  50  per  cent.),  mercurial  ointment, 
cantharideal  collodion,  and  evaporating  lotions  may  be  of  benefit.  If  the 
effusion  is  marked,  aspiration  under  the  most  rigid  aseptic  precautions  should 
be  performed  and  careful  search  made  for  the  gonococcus.  If  found  to  be 
present,  the  joint  should  be  incised,  thoroughly  irrigated  with  salt  solution 
or  a  weak  solution  of  bichlorid  of  mercury,  and  closed  with  or  without  drain- 
age. If  the  symptoms  are  very  acute,  it  is  advisable  to  open  the  joint  and  thor- 
oughly irrigate,  even  though  repeated  examinations  of  the  aspirated  fluid  faU  to 
reveal  the  presence  of  the  gonococci,  as  it  should  be  remembered  from  the  cases 


NON-TUBERCULOUS  JOINT  DISEASES.  533 

cited  above  ithat  they  may  not  be  demonstrated  in  the  fluid  and  yet  be  present  in 
the  granulation  tissue.  In  some  cases  after  arthrotomy  has  been  performed  it 
may  be  advisable  to  remove  extensively  the  involved  portions  of  the  synovial 
membrane.  When  the  fluid  is  sero-purulent,  drainage  should  be  instituted, 
and  continued  for  a  number  of  days.  It  should  be  remembered  that  in  order 
to  save  the  function  of  the  joint  one  should  not  wait  until  the  disease  is  far 
advanced  before  performing  arthrotomy,  as  this  only  relieves  the  infection,  but 
this  should  be  done  early  before  the  synovial  membrane  is  destroyed  and  fibrous 
resolution  has  taken  place.  If  this  is  done  early,  there  vpill  be  very  few  cases 
with  any  marked  limitations  of  motion,  and  practically  none  with  ankylosis. 

If  the  case  is  chronic  and  marked  induration  of  the  intra-articular  and 
extra-articular  structures  has  taken  place,  the  course  of  the  disease  wiU  be  short- 
ened and  better  functional  results  obtained  by  arthrotomy  and  excision  of  the 
diseased  portions  of  the  synovial  membrane.  If  this  is  not  considered  advis- 
able, the  absorption  of  the  exudate  may  be  hastened  by  the  use  of  hot  air, 
massage,  and  passive  and  active  movements.  If  ankylosis  has  occurred,  it 
should  be  remembered  that  in  most  cases  it  is  fibrous  in  character  and  can 
readily  be  overcome  by  repeated  forcible  movements  under  general  anesthesia. 
By  this  means  and  by  persistent  voluntary  movements  a  considerable  range  of 
motion  may  be  obtained  in  joints  in  which  motion  is  markedly  restricted. 

Acute  Articular  Rheumatism. 

While  the  condition  known  as  acute  articular  rheumatism  rarely  demands 
surgical  intervention,  yet  it  is  so  intimately  related  with  certain  forms  of  joint 
disease  that  a  consideration  of  it  will  materially  aid  us  in  making  differential 
diagnosis  in  certain  cases.  Many  cases  of  arthritis  in  the  early  stages  closely 
resemble  this  condition,  and  many  obscure  cases,  the  exact  cause  and  the  posi- 
tive diagnosis  of  which  are  uncertain,  are  classified  as  "rheumatic"  by  many 
physicians. 

Acute  articular  rheumatism  is  an  affection  of  adolescence  and  of  early 
adult  and  middle  life.  The  condition  may  be  monarticular  or  polyarticular. 
The  larger  joints  of  the  body  are  chiefly  affected  in  the  following  order:  knee, 
ankle,  elbow,  viTist,  shoulder,  hip,  and  smaU  joints  of  the  foot  and  hand.  The 
condition  is  often  foflowed  by  endocarditis,  pericarditis,  pleuritis,  etc. 

Etiology, — The  predisposing  causes  of  this  disease  are  exposure  to  cold 
and  wet,  living  in  damp  or  unhealthful  surroundings,  sudden  chilling  of  the 
body,  etc.     While  the  evidence  of  the  presence  of  a  pyogenic  organism  as  the 


534  ORTHOPEDIC  SURGERY. 

direct  and  only  cause  of  acute  articular  rheumatism  is  not  entirely  proved, 
yet  experiments  made  upon  animals  and  the  results  compared  with  the  similar 
pathologic  changes  observed  in  the  joints  of  man  show  that  the  infectious  nature 
of  the  disease  is  not  only  possible  but  probable.  Meyer  describes  a  diplostrep- 
tococcus  which  he  believes  to  be  the  cause  of  rheumatism.  Experiments  made 
with  this  organism  on  the  lower  animals  produced  typical  attacks  of  arthritis 
and  in  21  out  of  loo  cases  verrucose  endocarditis.  Other  experiments  have 
been  made  by  different  observers  with  various  organisms  with  similar  results. 
It  seems  very  probable  that,  as  certain  forms  of  arthritis  are  due  to  different 
specific  organisms  which  produce  pathologic  changes  and  clinical  symptoms 
entirely  distinct  from  each  other,  acute  articular  rheumatism  is  due  to  an  organ- 
ism which  produces  its  own  certain  train  of  phenomena.  It  is  commonly 
supposed  that  the  organisms  gain  entry  to  the  circulation  through  the  tonsils. 

Pathology. — The  articular  changes  which  take  place  in  acute  articular 
rheumatism  generally  involve  the  synovial  membrane.  Slight  effusion  is  always 
present.  Hypertrophy  of  the  villi  with  thickening  of  the  capsule  takes  place. 
The  cartilage,  while  usually  remaining  intact,  may  become  eroded  in  spots 
and  present  a  frayed-out  appearance.  As  the  villi  hypertrophy  the  joint  cavity 
is  increased,  fibrous  deposits  occur,  which  later  organize,  producing  in  chronic 
cases  marked  contraction  of  the  capsule.  Effusion  is  not  always  present,  but 
when  it  occurs  it  is  sero-fibrinous  or  flocculent. 

Symptoms. — The  acute  attack  generally  comes  on  suddenly  after  expo- 
sure. Several  joints  are  involved  at  the  same  time.  All  the  affected  joints 
may  not  present  the  same  set  of  symptoms.  Several  joints  may  be  very  pain- 
ful, while  others  may  be  markedly  swollen.  The  skin  surrounding  the  joint 
is  swollen,  tense,  reddened,  and  shows  increased  local  temperature;  in  fact, 
these  latter  symptoms  may  be  so  severe  as  to  suggest  a  suppurative  arthritis. 
Areas  of  induration  and  subcutaneous  ecchymosis  may  be  present.  The 
joints  are  held  rigid,  in  a  semi-flexed  position,  and  all  motion  is  prevented 
by  marked  muscular  spasm.  During  the  acute  attack  there  is  considerable 
constitutional  disturbance  and  increased  body-temperature.  Under  appro- 
priate treatment  the  recovery  from  the  acute  attack  is  very  rapid.  In  the 
chronic  condition  passive  motion  is  somewhat  limited  and  crepitus  can  generally 
be  elicited  over  the  affected  joints.  After  long  use  the  joint  may  be  swollen 
for  a  few  hours,  when  it  returns  to  normal  or  may  remain  stationary  for  weeks 
in  neglected  cases.  The  acute  condition  is  followed  very  frequently  by  endo- 
carditis, pericarditis,  pleurisy,  and  chorea. 


NON-TUBERCULOUS  JOINT  DISEASES.  535 

Diagnosis. — This  rests  upon  the  acuteness  of  the  onset,  the  polyarticular 
involvement,  the  absence  of  lymphangitis,  the  absence  of  leukocytosis,  the  his- 
tory of  previous  attacks,  and  the  rapid  subsidence  under  appropriate  treatment. 
The  chronic  form  is  recognized  by  the  history  of  previous  attacks  of  the  acute 
process,  by  the  local  examination  of  the  joints,  which  usually  present  crepitus 
on  motion,  and  stiffness  and  moderate  deformity. 

Treatment. — The  treatment  of  the  acute  form  consists  mainly  in  the 
internal  administration  of  preparations  of  salicylic  acid,  antipyrin,  arsenic, 
potassium  iodid,  etc.,  and  in  the  local  use  of  ichthyol,  gaultheria,  methyl  sali- 
cylate, etc.  Occasionally  good  results  follow  the  prolonged  use  of  various 
baths.  Good  results  often  follow  the  use  of  hot  air,  especially  in  the  chronic 
cases.  After  the  urgent  symptoms  have  subsided  careful  gymnastics,  mas- 
sage, hot  air,  and  electricity  may  be  employed.  Apparatus  which  produce 
complete  immobilization  should  never  be  used,  as  they  only  tend  to  increase 
the  stiffness  in  the  chronic  cases. 

Gout. 

Synon3ans. — Arthritis  urica ;  Podagra. 

The  constitutional  disease  commonly  known  as  gout  is  occasionally  accom- 
panied by  joint  affection.  While  gout  has  always  been  considered  as  being 
rare  in  this  country,  the  statistics  of  Fletcher,  collected  from  the  medical  clinic 
of  the  Johns  Hopkins  Hospital,  showing  that  there  were  32  cases  of  definite 
gout  among  14,000  patients  admitted  during  a  period  of  twelve  years,  prove 
that  the  condition  is  more  frequent  than  is  generally  supposed. 

The  disease  usually  begins  as  an  acute  attack,  lasts  several  days,  and  sub- 
sides suddenly.  The  metatarso-phalangeal  joint  of  the  great  toe  is  most  fre- 
quently affected,  although  involvement  of  the  joints  of  the  fingers  and  the 
knee-joint  and  the  elbow-joint  occasionally  occur. 

Pathology. — The  pathologic  changes  which  take  place  in  the  arthritis 
of  gout  are  characteristic.  There  occurs  an  acute  inflammatory  process  of 
the  synovial  membrane,  followed  by  thickening,  together  with  marked  degen- 
eration and  erosion  of  the  cartUage ;  at  the  same  time  a  deposit  of  uric  acid  salt 
crystals  takes  place  over  the  surface  of  the  synovial  membrane  and  cartilage. 
The  destruction  of  the  joint  is  due  to  deposits  of  these  crystals  beneath  the  car- 
tilage and  the  formation  of  localized  deposits  of  uric  acid  containing  material 
resembling  chalk  (gout  nodules,  tophi).  Similar  deposits  take  place  in  the 
soft  parts  and  true  exostoses  occur.     The  s}Tiovial  membrane  remains  thick- 


536  ORTHOPEDIC  SURGERY. 

ened.  The  deposits  become  palpable  and  may  be  recognized  by  a  sand-like 
grating  or  may  produce  yellow  foci  which  are  evident  under  the  inflamed  skin. 
Occasionally  the  deposits  break  down,  suppurate,  and  lead  to  the  formation 
of  fistulas. 

Symptoms. — The  onset  of  an  attack  is  sudden.  It  begins  as  an  acute 
swelling  of  the  joint,  accompanied  by  intense  pain  and  redness  of  the  skin. 
The  attack  lasts  several  days  and  gradually  subsides.  Repetitions  of  the  acute 
attacks  are  followed  by  the  formation  of  the  deposits  mentioned  above.  At 
the  time  of  the  acute  attack  there  is  never  any  involvement  of  the  lymphatic 
system  or  signs  of  inflammation  in  the  neighboring  lymph-nodes. 

Diagnosis. — This  depends  upon  the  history,  the  sudden  onset,  the  gradual 
improvement  after  several  days,  followed  by  the  characteristic  deposits,  the 
absence  of  signs  of  acute  sepsis,  and  the  absence  of  constitutional  symptoms. 

Treatment. — While  the  treatment  of  most  cases  of  gouty  arthritis  belongs 
to  medicine,  yet  the  surgeon  is  occasionally  called  upon  to  excise  bursae  and 
to  excise  joints  which  are  hopelessly  deformed  by  the  presence  of  uric  acid 
deposits.  Excision  of  joints  which  are  very  painful  on  account  of  pressure, 
or  are  ankylosed  in  deformed  positions,  is  followed  by  marked  relief,  although 
the  operation  does  not  prevent  subsequent  deposits  from  taking  place  in  the  soft 
parts  about  the  excised  jomt. 

Hemopliilia. 

The  occurrence  of  joint  lesions  in  hemophilia  is  very  rare.  Bloodgood 
states  that  there  has  never  been  observed  a  case  of  hemophilia  with  joint  mani- 
festations at  the  Johns  Hopkins  Hospital,  although  there  have  been  several 
cases  of  the  disease  treated  there.  The  condition  is  usually  observed  in  the 
male  sex  during  chUdhood  or  early  adult  life.  There  is  generally  a  family  or 
previous  personal  history  of  hemophilia.  The  knee-joint  is  most  frequently 
affected,  although  several  joints  may  be  simultaneously  affected.  The  attack 
usually  follows  an  injury  or  may  come  on  suddenly  and  spontaneously  during 
the  night  without  any  previous  history  of  trauma. 

Pathology. — The  pathologic  changes  consist  of  hemorrhage,  which  may 
be  intra-articular  and  extra-articular.  After  repeated  attacks,  the  vUli  are 
increased  and  the  cartilage  is  stained  brownish  and  may  be  in  a  stage  of  degen- 
eration, exposing  the  bone  in  places.  Erosion  of  the  ends  of  the  bones  may 
take  place  in  the  center  combined  with  proliferation  along  the  periphery.  Fibrin 
is  deposited  upon  the  synovial  membrane  and  cartilage  and  later  becomes 


NON-TUBERCULOUS  JOINT  DISEASES.  537 

organized,  producing  adliesions  between  the  articular  surface,  contractures  of 
the  synovial  membrane,  and  marked  impairment  of  motion.  If  erosion  of  the 
cartilage  and  bone  ends  takes  place,  the  destructive  process  may  continue  until 
complete  disorganization  of  the  joint  occurs.  Contractures,  deformities,  and 
ankylosis  are  usually  the  end  results. 

Symptoms. — In  most  cases  there  is  usually  the  family  history  of  hemo- 
philia or  a  previous  personal  history  of  epistaxis  or  some  other  form  of  hemor- 
rhage. The  joint  symptoms  may  follov^r  injury  or  may  occur  spontaneously 
during  the  night,  without  pain,  fever,  or  functional  disturbance.  There  is  con- 
siderable swelling  and  moderate  impairment  of  motion.  The  swelling  produces 
the  ordinary  symptoms  of  an  acute  synovitis.  Several  days  after  the  onset 
there  may  be  signs  of  extravasated  blood  around  the  joint.  The  symptoms  of 
the  attack  may  disappear  and  be  followed  by  a  succession  of  attacks  in  the  same 
or  other  joints,  until  finally  there  is  persistent  swelling,  induration  of  the  soft 
parts,  moderate  muscular  atrophy,  limitation  of  motion,  until  the  joint  symptoms 
pass  on  to  a  chronic  state,  and  finally  contractures,  ankylosis,  and  deformity 
occur. 

Diagnosis. — The  diagnosis  rests  upon  the  hemophilia  history,  the  occur- 
rence of  an  acute  attack  of  arthritis,  which  may  be  followed  by  further  slight 
attacks  of  swelling,  pain,  and  perhaps  subcutaneous  ecchymosis  appearing 
several  days  after  the  onset.  The  persistence  of  the  condition  foUowed  by  the 
ankylosis  and  deformity  may  aid  in  arriving  at  a  correct  diagnosis.  The  con- 
dition is  often  confounded  with  that  of  tuberculous  knee-joint  disease.  Konig 
on  two  occasions  operated  on  what  he  considered  .was  tuberculous  arthritis 
of  the  knee,  and  the  operation  was  followed  by  almost  fatal  results  from  hemor- 
rhage on  account  of  the  condition  being  hemophilia.  If  a  surgeon  of  Konig's 
experience  is  mistaken  in  this  condition,  the  difficulties  that  are  occasionally 
encountered  in  arriving  at  a  correct  diagnosis  can  be  readily  seen. 

Treatment. — During  the  acute  attack  the  joint  should  be  tightly  bandaged 
and  immobilized  by  a  suitable  splint.  If  repeated  attacks  occur,  care  should 
be  taken  to  place  the  limb  by  appropriate  apparatus  in  the  best  functional  posi- 
tion, should  ankylosis  occur.  The  only  operative  treatment  advisable  is  aspira- 
tion of  the  fluid  and  the  irrigation  with  carbolic  acid,  or  aspiration  followed 
by  the  injection  of  gelatin  (20  to  40  c.c.  of  a  2  per  cent,  solution)  into  the  joint. 
Arthrotomy  is  contraindicated  on  account  of  the  fatal  hemorrhage  which  is  liable 
to  follow.  Fuller  reports  two  cases,  in  which  after  the  administration  of  thyroid 
extract,  in  five-grain  doses  three  times  daily,  there  was  no  recurrence  of  the 


538  ORTHOPEDIC  SURGERY. 

condition.  If  contractures  and  ankylosis  in  deformed  positions  occur,  forcible 
correction  or  operative  interference  should  never  be  attempted.  If  attempts 
are  made  to  overcome  the  deformity  in  the  early  stages  by  gradual  extension, 
good  results  will  usually  follow. 

Scorbutus. 

Synonym. — Infantile  scurvy. 

The  occurrence  of  joint  disease  in  infantile  scurvy,  while  uncommon,  is 
occasionally  seen.  The  condition  is  usually  found  among  children  who  are 
poorly  nourished  and  poorly  fed.  It  generally  occurs  among  children  who  are 
fed  on  cows'  milk. 

Pathology. — The  pathologic  changes  consist  of  an  enlargement  of  the 
end  of  one  of  the  bones  forming  an  articulation  due  to  a  periosteitis,  and  are 
accompanied  by  a  subperiosteal  hemorrhage.  The  process  usually  occurs  near 
the  epiphyseal  line,  and  may  be  so  extensive  that  epiphyseal  separations  may 
result.  The  process  does  not  usually  involve  the  joint,  although  a  sympathetic 
S)Tiovitis  may  be  present. 

Symptoms. — The  condition  is  first  noticeable  on  account  of  the  child 
complaining  of  pain  and  tenderness  about  the  affected  joint,  which  on  exam- 
ination is  found  to  be  enlarged  and  tender  on  pressure.  The  swelling  is  gener- 
ally extra-articular  and  above  the  epiphysis,  although  some  joint  effusion  may 
be  present.  There  are  no  signs  of  an  acute  inflammatory  condition,  as  local 
heat,  redness,  or  edema.  Peri-articular  ecchymosis  may  be  present.  In  addition 
to  the  joint  lesions  there  may  be  marked  hemorrhages  beneath  the  mucous 
membranes  and  the  skin.     There  is  generally  a  coexistent  condition  of  rachitis. 

Treatment. — The  chief  point  of  treatment  consists  in  substituting  fresh 
milk,  properly  modified,  to  suit  the  case,  for  condensed  or  improperly  prepared 
milk.  To  this  should  be  added  fruits  and  juices  which  contain  citric  acid. 
During  the  acute  stage  protection  should  be  afforded  the  involved  extremities 
so  as  to  prevent  epiphyseal  separation  or  fracture,  and  during  the  convalescence 
the  general  health  should  be  improved  by  massage  and  bathing. 


CHAPTER  XVII. 
LATERAL  CURVATURE  OF  THE  SPINE. 

Lateral  curvature  of  the  spine  is  a  lateral  deviation  of  the  spinal  column, 
or  part  of  it,  from  the  natural  physiologic  direction  to  either  side  of  the  median 
line,  associated  with  a  distortion  of  the  trunk.  This  deviation  is  usually  accom- 
panied with  rotation  of  the  bodies  of  the  vertebras  on  their  vertical  axes,  but  as 
this  is  not  essential,  it  need  not  necessarily  form  a  part  of  the  definition  of  the 
deformity.  Two  forms  are  recognized — a  functional  and  a  rotary  lateral 
curvature. 

Synonyms. — English,  Scoliosis.  German,  Seitliche  Rlickgratsverkrum- 
mung,  oder  Verbiegung;  Bogenformige  Deformitat  der  Wirbelsaule ;  Seitliche 
Verbiegung.  i^'/rnc/j,  Scoliose;  Deviation  Laterale  de  la  Taille.  /to//a»,  Scoliosi. 
Spanish,  Scoliosis.  All  of  these  express  clearly  the  deformity,  but  for  scien- 
tific purposes  the  term  scoliosis,  which  was  given  to  this  affection  by  Hippocrates, 
is  open  to  least  objection,  and  is  the  one  generally  employed. 

Frequency. 

Lateral  curvature  is  much  more  frequent  than  the  ordinary  observer  would 
imagine,  from  the  fact  that  by  the  proper  arrangement  of  the  clothing  deformities 
of  slight  degree  are  readily  concealed.  It  is  also,  without  doubt,  the  most 
common  of  all  orthopedic  affections.  Drachmann  found  in  28,125  children 
examined  in  the  schools  of  Denmark  368  suffering  from  this  affection,  and 
more  recently  Scholder,  out  of  2315  school-children  examined,  found  scoliosis 
present  in  571.  Combining,  however,  the  8000  cases  of  deformity  examined 
by  Schilling,  Berend  and  Langaard,  and  Fischer,  2553  of  whom  suffered  from 
scoliosis,  we  have  a  sufficiently  large  number  to  show  the  frequency  of  this 
affection.  The  relative  frequency  of  this  affection  in  surgical  fracture  is  shown 
in  the  5680  cases  of  orthopedic  affections  treated  at  the  Dispensary  of  the  Hos- 
pital of  the  University  of  Pennsylvania,  293  of  which  had  scoliosis  and  492 
Pott's  disease. 

Taking  the  relative  frequency  among  boys  and  girls,  the  larger  percentage 
of  the  latter — about  four  to  seven  girls  to  one  boy — has  reasonably  been  ascribed 
to  the  greater  attention  given  to  their  development,  and  therefore  the  greater 

539 


540  ORTHOPEDIC  SURGERY. 

likelihood  of  an  early  recognition  of  the  deformity,  and  consequently  an  earlier 
consultation  with  the  surgeon.  This  statement  seems  to  be  supported  by  the 
fact  that  of  all  those  cases  of  scoliosis  seen  by  the  surgeon,  the  most  aggravated 
forms  are  found  among  males,  the  earlier  or  milder  cases  being  found  in  females, 
though  severe  cases  may  also  be  found  in  females.  The  most  severe  form  the 
writer  has  observed  was  in  a  female  of  thirty-five  years. 

This  relative  proportion  is  found  from  the  following  table  to  amount  to 
78.8  per  cent. 

Number  Examined.  Boys.  Girls. 

KoUiker, 721  144  577 

Roth,  1000  122  878 

Wildberger, 120  19  loi 

Lonsdale, 179  21  149 

Ketch,  229  40  189 

Berend,  896  123  773 

Adams, 173  22  151 

3318  491  2816 

In  very  young  children  under  five  years  of  age,  the  number  of  males  was 
found  by  Redard  to  equal  or  even  exceed  the  number  of  females. 

The  relative  frequency  at  different  periods  of  life  is  well  shown  by  the 
analysis  of  1000  cases  made  by  Roth,  in  which  he  found  the  average  age  to 
have  been  12.32  years,  and  the  greatest  number  of  cases  (11.7  per  cent.)  to  have 
occurred  at  the  age  of  thirteen.  Scholder  practically  confirms  Roth's  figures, 
for  in  his  examination  of  2315  school-chUdren  he  found  571  were  scoliotics,  of 
whom  20.14  per  cent,  were  thirteen,  18.39  per  cent,  were  twelve,  and  19.26 
per  cent,  were  eleven  years  of  age. 

Likewise  in  Eulenburg's  1000  collected  cases,  in  85.8  per  cent,  the  deformity 
began  before  the  tenth  year,  in  96.5  per  cent,  before  the  fourteenth  year,  and 
in  only  3.5  per  cent,  after  the  fourteenth  year.  His  figures  are  as  follows:  78 
cases  from  birth  to  the  sixth  year;  216  from  sixth  to  seventh;  564  from  seventh 
to  tenth;  107  from  tenth  to  fourteenth;  35  after  the  fourteenth.  It  therefore 
occurs  most  frequently  before  puberty,  and  more  particularly  between  the 
tenth  and  thirteenth  years  of  life,  especially  the  latter. 

As  to  the  relative  frequency  among  school- children,  the  following  are  reported : 

Hagman,  of  Moscow, in  1664  children  found  29%       scoliotic. 

Guillaume,  of  Neufchatel, "    731        "  "       29%  " 

Kallbach,  of  St.  Petersburg, "2333        "  "       26%  " 

Krug,  of  Dresden, "  141S        "  "       25%  " 

Scholder,  of  Lausanne, "2314       "  "       24.67%        " 


LATERAL  CURVATURE  OF  THE  SPINE. 


541 


Scoliosis  is  of  greater  frequency  among  the  enlightened;  that  it  is  a  conse- 
quence of  civilization,  as  has  been  stated  by  several  authorities,  can  be  estab- 
lished, since  only  a  few  of  the  causes — congenital,  traumatic,  and  pathologic — 
occur  among  savages.  If,  however,  varieties  only  were  considered, — as  habitual, 
static,  and  professional — the  statement  would  be  accurate. 

Six  different  forms  of  scoliosis  may  be  considered,  as  follows: 
I.  Right  cervical  scoliosis. 


Fig.  367. — Primary  Right  Cervical  Scoliosis 


Fig.  36S. — Primary  Left  Cervical  Scoliosis. 


2.  Left  cervical  scoliosis. 

3.  Primary  right  dorsal  scoliosis. 

4.  Primary  left  dorsal  scoliosis. 

5.  Primary  right  lumbar  scoliosis. 

6.  Primary  left  lumbar  scoliosis. 

From  the  anatomic  construction  of  the  vertebral  column,  scoliosis  affects 
some  portions  of  the  spine  more  frequently  than  others,  the  right  dorsal  scoliosis 
being  by  far  the  most  frequent  as  a  primary  affection,  and  left  primary  lumbar 


542 


ORTHOPEDIC  SURGERY. 


scoliosis  next  in  order.  The  proportion  of  cases  of  primary  right  dorsal  scoliosis 
has  been  variously  estimated  from  42.3  per  cent.  (Drachmann)  to  92.7  per  cent. 
(Eulenberg).  Schulthess  found  90  per  cent,  left,  as  against  10  per  cent,  right. 
It  is  probable  that  primary  left  lumbar  scoliosis  is  relatively  more  frequent  than 
has  been  supposed,  Lorenz  having  found  38  per  cent.,  Drachmann  47.7  per  cent., 
and  Klopsch  57  per  cent,   in  their  investigations.     As  primary  curves  they 


Fig.  369. — Primary  Right  Dorsal  Scoliosis. 


Fig.  370. — Primary  Left  Dorsal  Scoliosis. 


rarely  exist  for  any  length  of  time,  being  sooner  or  later  associated  Avith  a  rotation 
of  the  bodies  of  the  vertebras,  and  a  secondary  or  even  tertiary  compensatory 
curve  to  enable  the  column  to  maintain  its  equilibrium.  Scholder  in  571  school- 
children found  that  401,  or  70.3  per  cent.,  were  single  left-sided;  121,  or  21.1 
per  cent.,  were  single  right-sided ;  and  49,  or  8.6  per  cent.,  were  combined  curves. 
According  to  Krug,  67  per  cent,  were  left,  21  per  cent,  were  right,  and  12  per 
cent,  were  combined. 


LATERAL  CURVATURE  OF  THE  SPINE. 


543 


Etiology. 

Congenital  scoliosis,  though  rare,  does  occur  as  a  consequence  of  other 
deformity  or  as  a  primary  malformation — a  vitium  prima  formationis — instances 
of  which  have  been  recorded.  In  Willett's  case,  an  adult  of  thirty-five  years, 
the  deformity  was  believed  to  be  due  to  an  early  embryologic  defect  in  the  ele- 
ments forming  the  .lateral  and  vertebral  plates.  Heredity  is  a  frequent  cause, 
especially  in  the  scoliosis  observed  in  young  girls,  about  25  per  cent,  being  due 
to  this  cause.  Hereditary  examples 
of  two  or  more  members  of  a  familv, 


Fig.  371. — Primary  Right  Lumbar  Scoliosis. 


Fig.  372. — Primary  Left  Lumbar  Scoliosis. 


while  the  mother  or  father  also  present  a  similar  deformity,  are  numerous  and 
familiar  to  all. 

By  far  the  greater  number,  however,  are  acquired.  As  an  acquired  affection 
it  arises  from  many  and  various  causes,  the  most  common  among  the  predispos- 
ing being  sex.  Thus,  the  deformity  is  observed  more  frequently  in  girls  than  in 
boys — according  to  the  statistics,  in  about  the  proportion  of  between  four  and 
seven  to  one.     Age  is  also  a  predisposing  cause. 

General  muscular  debility  in  adult  cases  has  but  little  weight,  since  the 


544 


ORTHOPEDIC  SURGERY. 


weak  and  delicate,  unless  as  an  acquired  cachexia  or  diathesis  the  result  of  pro- 
longed disease,  do  not  suffer  more  frequently  than  the  strong,  muscular,  and 
robust.  This  was  particularly  marked  in  several  cases  in  unusually  well-devel- 
oped boys  observed  by  the  writer.  In  the  majority  of  cases  in  the  young,  and 
especially  in  females,  the  muscular  development  is  decidedly  below  par,  the 
digestion  is  feeble,  the  circulation  poor,  and  they  are  subject  to  cold  hands  and 

feet,  intercostal  neuralgias,  and  occipital  head- 
aches. This  cannot  be  said,  however,  of  the 
general  debility  resulting  from  rachitis,  which 
has  been  considered  recently  by  one  authority 
as  one  of  the  most  common  predisposing  causes. 
When  the  number  of  bow-leg  and  knock-knee 
patients  is  considered,  it  is  remarkable  that 
lateral  bending  of  the  osseous  spinal  column 
does  not  with  greater  frequency  yield  to  like 
causes.  This,  it  may  be  suggested,  may  be 
due  to  the  enlarged  abdomen  and  ligamentous 
relaxation,  tending  toward  a  posterior  curva- 
ture rather  than  a  lateral  deviation. 

Later,  as  exciting  causes,  the  direct  results 
of  rachitis — bow-legs  and  knock-knees,  anterior 
bowing  of  the  femur  and  tibia,  fiat-foot,  etc. — 
contribute  their  quota  to  the  number  of  curva- 
ture cases.  The  habitual  position  in  which  in- 
fants are  carried  is  particularly  liable  to  pro- 
duce scoliosis,  especially  in  rachitic  cases. 

Under  exciting  causes  also  may  be  reck- 
oned all  those  influences  which  in  any 
manner  disturb  the  equilibrium  of  the  spinal  column,  and  which  give  to  the 
muscles  of  one  side  an  advantage  over  their  antagonists.  These  may  be  con- 
veniently classed  in  the  order  of  importance  and  frequency,  under  habitual, 
static,  professional  or  vocational,  pathologic,  and  traumatic. 

The  habit  scoliosis  which  results  from  the  partial  or  unequal  use  of  the 
muscular  system  is  equally,  if  not  more,  common  among  the  tailor-made  society 
misses  reared  and  instructed  in  the  environment  of  a  Procrustean  atmosphere, 
and  the  factory  slave  unaffected  by  proprieties  but  compelled  by  necessity  to 
assume  cramped  positions  for  long  periods  under  the  most  unhygienic  surround- 


FiG.  373. — Statue  of  Boy  from 
Pompeii  Showing  Attitude  of 
Rest. 


Fig.  374.-CURVE  Caused  bv  Faulty  Attitudk.  F:g.  375.-Same  Case,  showing  Corrected  Attitude. 


LATERAL  CURVATURE  OF  THE  SPINE.  547 

ings.  On  the  one  hand,  these  habitual  faulty  positions  are  assumed  through 
carelessness;  on  the  other,  through  fatigue.  This  attitude  of  rest  or  fatigue, 
which  I  have  designated  the  "American  position,"  is  very  commonly  depicted 
in  works  of  art.  Illustrations  of  this  are  seen  in  such  statues  as  the  Venus 
in  the  Naples  Museum,  the  Venus  in  the  Uffizi  Gallery,  and  in  the  Boy  from 
Pompeii.  This  attitude  of  rest  is  also  observed  in  the  paper  currency  issued 
by  the  United  States  Government  in  1898,  where  two  figures  are  shown  standing 
in  this  manner.  It  is  also  frequently  observed  in  soldiers'  monuments,  and  in 
many  statues  of  distinguished  men.  That  this  habitual  faulty  attitude  is  pro- 
ductive of  lateral  curvature  is  proved  in  instances  of  artist's  models  who  have 
become  deformed  from  assuming  this  position  for  long  periods.  The  exact 
manner  in  which  a  faulty  attitude  produces  lateral  curvature  is  not  difficult 
of  explanation.  The  constant  standing  upon  one  foot — as,  for  example,  the 
left — leads  to  an  elongation  of  the  flexed  and  relaxed  member,  so  that  when 
the  standing  position  is  assumed  the  relaxed  limb  is  apparently  longer  than 
the  one  upon  which  the  weight  has  rested.  Moreover,  the  elongated  one 
will  be  found  to  be  larger  in  circumference  and  the  muscles  relaxed  and 
softened.  Habitual  faulty  positions,  therefore,  constitute  by  far  the  larger  num- 
ber of  cases.  Under  this  class  belong  also  those  cases  resulting  from  lateral 
posture  assumed  to  relieve  ovarian  pain  (usually  left),  and  to  relieve  pain  and 
distention  from  enlarged  spleen. 

Static  scoliosis,  or  inequality  resulting  from  alterations  of  one  extremity, 
is  next  in  importance.  Whatever  produces  a  shortening  of  one  lower  extremity 
produces  an  obliquity  of  the  pelvis  in  the  opposite  direction,  and  a  primary 
deviation  of  the  lumbar  vertebras.  This  may  result  from  destructive  changes  in 
the  joints,  rachitic  curves  and  bowing,  flat-foot,  back-knee  from  ligamentous 
relaxation,  or  in  consequence  of  excisions  or  amputations  of  either  the  lower  or 
upper  extremities.  The  exact  production  of  scoliosis  in  cases  of  amputation  is 
difficult  to  explain  satisfactorily,  since  a  person  with  an  amputated  arm  may  have 
scoliosis,  while  another  with  an  amputated  leg  may  not.  The  existence  of  a 
short  leg  from  unilateral  development  is  also  very  frequent,  since  Morton  found 
in  513  healthy  boys  measured,  272  with  inequality  in  the  length  of  their  legs, 
and  Garson,  in  London,  in  measuring  the  leg  bones  in  70  skeletons  found  only 
10  per  cent,  with  legs  of  equal  length. 

Professional  or  vocational  scoliosis,  so  called,  results  from  oblique 
positions  assumed  during  occupations.  Particularly  fruitful  of  deformity  are 
the  faulty  positions  assumed  during  writing,  violin-playing,  and  the  oblique 


548. 


ORTHOPEDIC  SURGERY. 


attitudes  required  in  bearing  burdens.  Among  these  may  be  mentioned  mu- 
sicians— especially  violinists — dentists,  barbers,  nurses,  cow-boys,  drug  clerks, 
dressmakers,  loom-workers,  girls  who  ride  horseback,  persons  born  in  the  tropics, 
jewelers,  umbrella-makers,  professional  models,  etc.  Those  whose  occupation 
requires  them  to  bear  heavy  burdens  upon  one  side  are  liable  to  acquire  lateral 
curvature  especially  in  their  youth,  among  which  Bishop  has  called  attention  to 
"water-men,  waiters,  harp-players,  porters,  and  London  milkmen,"  and  Ridlon 
has  noted  the  absence  of  curvature  in  men  who  carry  heavy  kegs  of  beer  upon 
the  same  shoulder  during  many  years.  In  my  opinion  the  absence  of  any 
curvature  in  these  instances  is  due  to  the  fact  that  this  occupation  is  not  adopted 
until  the  individual  has  arrived  at  adult  life,  when  the  body  is  fully  formed. 


Fig.  376. — Faulty  Position  Tending  to  Right- 
sided  Total  Scoliosis  (Hoffa). 


Fig.  377. — Faulty  Position  Tending  to  Double 
Curve  (Hoffa).    ^. 


In  the  Siamese  twins  the  lateral  curvature  resulted  from  the  effort  which 
each  made  to  give  the  other  more  space  in  standing,  the  one  shoulder  of  each, 
on  opposite  sides,  being  always  elevated.  The  same  condition  has  been 
observed  in  twin  sisters  who  were  crowded  in  a  narrow  school  seat  and  who 
rested  continually  upon  opposite  elbows  in  endeavoring  to  make  room  for 
each  other.  I  have  also  noted  the  same  condition  in  two  Irish  brothers, 
the  one  left-handed  and  the  other  right-handed,  who  sat  in  the  same  seat 
at  school,  and  who  developed  curvature  in  the  opposite  direction  from  the 
elevation  of  the  shoulders. 

Pathologic  scoliosis  is  exceptional,  but  may  result  from  certain  inflam- 
matory conditions,  such  as  torticollis;  cicatrices  from  burns;  phlegmons;  caries 
or  necrosis  of  ribs,  etc.;  pleuritic  affections,  especially  empyema.  Pleural 
pneumonia  is  a  very  frequent  source  of  lateral  curvature,  the  cicatricial  con- 


LATERAL  CURVATURE  OF  THE  SPINE. 


549 


traction  producing  a  marked  depression  and  iixation  of  the  affected  side  with 
an  undue  development  of  the  normal  side  of  the  chest.  Certain  muscular 
conditions,  as  spasms;  unilateral  muscular  atrophy  and  hypertrophy;  muscular 
rheumatism  (myositis);  sciatica  and  other  nerve  conditions;  neurotic  changes, 
either  akinetic  or  hyperkinetic,  especially  the  former,  of  which  anterior  polio- 
myelitis is  the  commonest  example,  may  cause  scoliosis.  In  infantile  paralysis 
the  curvature  may  result  in  two  ways:  first,  from  the  paralysis  of  the  muscles 
upon  one  side  of  the  spine,  and,  second,  from  the  inequality  of  the  lower  extrem- 
ities produced  by  the  atrophy  of  the  affected  limb.  Morbid  growths  of  the  sides 
of  the  pelvis  or  trunk — as  encephaloid,  enchondroma  or  sarcoma — by  their  enor- 
mous weight;  and  sacro-iliac  disease  from  the  habitual 
faulty  position  assumed  to  relieve  suffering,  may  produce 
scoliosis. 

Among  the  rare  causes  of  scoliosis  should  be  men- 
tioned that  form  resulting  from  neuromuscular  changes — 
scoliosis  neuromuscularia  ischiadica,  described  by  Beely. 
This  condition  is,  in  my  observation,  usually  a  peripheral 
neuritis,  the  result  of  exposure  to  great  and  sudden  changes 
of  temperature. 

Hysteric  scoliosis  is  also  exceedingly  rare,  but  is  occa- 
sionally observed. 

Trauma  is  exceedingly  rare  as  a  cause,  since  frac- 
tures of  the  bodies  or  processes  of  the  vertebras  are  more 

liable  to  produce  anteroposterior  curvature.  Non-reduced  lateral  dislocations 
would  lead  to  permanent  lateral  deformity,  as  might  also  gunshot  wounds  of 
this  region. 


Fig.    378. — Severe   Sco- 
liosis FROM  Empyema. 


Pathology. 

The  pathologic  anatomy  of  advanced  scoliosis  includes  changes  in  the  osse- 
ous, ligamentous,  inter-cartilaginous,  and  muscular  structures  in  the  order  of 
importance.  In  the  early  stages  the  change  is  probably  first  in  the  inter- 
cartilaginous  disks. 

The  lesions  which  occur  during  the  early  stages  are  necessarily  poorly  under- 
stood, from  the  difficulty  of  obtaining  post-mortem  specimens  at  this  period. 

It  is  important  to  study  the  normal  curves,  and  the  rotation  of  the  bodies 
of  the  vertebras  in  the  normal  spine,  in  order  to  understand  the  occurrence 
of  rotation  in  lateral  curvature. 


550  ORTHOPEDIC  SURGERY. 

At  birth  the  primary  curves  are  in  the  dorsal  region  and  are  produced  by 
the  shape  of  the  bodies  of  the  vertebras  in  this  region.  Cervical  and  lumbar 
curves  develop  after  birth,  being  secondary  or  compensatory  curves  for  the  pur- 
pose of  re-establishing  the  equilibrium,  the  changes  taking  place  by  compression 
of  the  intervertebral  disks.  A  slight  lateral  curve  is  normal  in  the  dorsal 
region,  being  chiefly  due  to  muscular  action,  as  pointed  out  by  Bichet,  whose 
theory  was  confirmed  by  Bechard,  who  found  a  left  lateral  curve  in  one  or  two 
individuals  who  were  left-handed.  In  some  instances  a  number  of  small  curves 
may  be  observed  which  are  usually  associated  with  neurasthenia,  and  which 
indicate  a  weak  back,  not  necessarily  a  lateral  curvature.  The  writer  has  ob- 
served this  condition  in  a  patient  upon  whom  an  unsuccessful  attempt  had  been 
made  to  correct  a  lateral  curvature  by  means  of  machines. 

Rotation  of  the  bodies  of  the  vertebras  occurs  in  the  normal  spine  because 
the  anterior  part  of  the  column  is  freely  movable  in  the  cavity  of  the  abdomen 
and  chest,  whUe  the  posterior  part  is  fixed  by  the  attachment  of  the  muscles, 
fascias,  ribs,  etc.  The  rotation  which  occurs  physiologically  is  produced  in  a 
single  vertebra  by  a  lateral  movement  of  the  body,  which  is  three  times  as  much 
as  the  movement  of  the  process.  The  rotation  does  not  occur  upon  a  central 
axis  of  the  body  of  the  vertebra,  nor  does  it  occur  upon  a  central  axis  passing 
through  the  spinal  canal,  but,  according  to  Judson,  it  rotates  upon  an  axis  some- 
what remote  from  the  periphery  and  at  a  point  indeterminable  and  probably  vari- 
able. The  rotation  varies  in  different  parts  of  the  column,  and  it  is  claimed  that 
in  the  cervical  region  no  rotation  occurs  because  there  is  no  cavity  corresponding 
to  the  abdominal  and  thoracic  cavities.  From  the  experiments  of  Lovett  it  would 
appear  to  be  conclusively  proved  that  lateral  bending  as  a  single  movement  is  im- 
possible. When  the  body  is  bent  sideways,  it  is  accomplished  by  a  combination 
with  rotation.  Torsion  occurs  by  a  combination  of  these  two  movements,  and  is 
best  illustrated  by  the  bending  of  a  flat,  flexible  object  in  the  du-ection  of  its  width. 
The  beiiding  of  an  object  of  this  kind  shows  that  when  bent  in  the  direction  of 
its  width,  rotation  upon  its  axis  must  occur.  It  has  been  further  demonstrated 
that  a  soldier,  for  example,  can  only  accomplish  side-bending  in  the  extended 
position,  torsion  being  best  accomplished  when  the  body  is  flexed  at  about  15 
degrees. 

In  order  to  study  the  loss  of  equilibrium  in  lateral  curvature  it  is  necessary 
to  keep  in  mmd  the  constant  balancing  of  the  body  which  maintains  the  center 
of  gravity.  I  have  corroborated  the  experiments  of  Weber  in  regard  to  the  center 
of  gravity  in  the  horizontal  and  vertical  positions.     It  was  asserted  that  the 


LATERAL  CURVATURE  OF  THE  SPINE. 


551 


center  of  gravity  would  fall  between  the  feet,  and  that  when  the  feet  were  equally 
inclined  and  equally  advanced  the  distance  between  the  heels  would  corre- 
spond to  the  length  of  the  foot,  and  the  angle  would  be  exactly  60  degrees.  In 
this  position  the  equilibrium  is  most  easily  sustained.  If  the  heels  are  brought 
together,  the  angle  is  changed  to  45  degrees. 

In  order  to  determine  the  angle  of  inclination,  if  the  mediotarsal  joint  is 
used  as  the  base-line  and  a  perpendicular  is  erected  to  the  axis  of  the  calcaneum, 
an  imaginary  line  being  drawn  through  the  foot  longitudinally,  as  was  done 
by  Bishop  in  determining 
the  angle,  it  will  be  found 
that  the  angle  wUl  be  60 
degrees  when  the  heels  are 
placed  together. 

That  occupation  is 
sometimes  responsible  for 
the  occurrence  of  lateral 
curvature  is  shown  in  the 
fact  that  in  carrying  heavy 
weights,  and  at  the  same 
time  endeavoring  to  main- 
tain the  equilibrium,  the 
body  deviates  to  the  oppo- 
site side  of  the  vertical 
plane,  thus  producing  a 
curvature. 

In  a  well-marked 
specimen  the  following  changes  are  observed:  The  vertebras  are  rotated 
horizontally,  the  excess  of  the  displacement  being  in  the  anterior  portion 
(the  bodies).  The  spinous  processes  being  comparatively  fixed,  any  motion 
of  the  column  is  observed  to  result  in  a  torsion  or  rotation  of  the  bodies  of 
the  vertebras.  This  is  in  all  probability  what  occurs  in  man,  since  the  human 
spine  is  endowed  with  but  a  slight  degree  of  pure  sidewise  motion,  so  fully  de- 
veloped in  amphibia,  in  reptiles,  and  in  some  mammals.  The  concave  side  of 
the  body  is  atrophied,  and  in  some  cases  ossified  to  the  adjacent  vertebra  by  a 
mild  pressure  osteitis,  the  result  being  a  wedge-shaped  body  with  the  base  toward 
the  convexity.  The  root  of  the  arch  is  shortened  on  the  side,  the  vertebral  canal 
is  ovoidal  from  pressure,  and  even  the  bony  fibers  of  the  body  occupy  a  peculiar 


Fig.  379.- 


-OuTLiNE  OF  Feet,  showing  Angle  of  Inclination, 
AND  ALSO  Angle  of  Feet  in  Standing. 


552 


ORTHOPEDIC  SURGERY. 


oblique  instead  of  an  upright  position.  The  ribs  being  patched  to  the  verte- 
bras, are  also  much  altered  in  general  outline.  On  the  concave  side  they  are 
depressed,  the  angle  is  more  acute,  and  may  be  united  where  they  approxi- 
mate by  synostoses.  On  the 
convex  side  they  are  depressed, 
vi^idely  separated  from  each  other, 
and  the  angle  is  obtuse.  From 
these  changes  in  the  vertebras 
and  ribs,  the  axis  of  the  cavity 
of  the  thorax  is  oblique,  the 
horizontal  section  representing 
an  ellipsoid  the  greater  axis  of 
which  is  formed  by  the  convex 
curvature,  the  lesser  by  the  con- 
cave diameter. 

The  pelvis  occupies  an  ob- 
lique position  in  the  static  cases, 
but  in  others  it  is  more  often  hori- 
zontal than  is  generally  believed. 
The  changes  occurring  in  the 
intervertebral  disks  take  place 
early,  and  are  marked.  When 
we  consider  that  the  total  thick- 
ness of  all  the  intervertebral 
bodies  forms  about  one-fourth 
of  the  spinal  column  exclusive 
of  the  first  two  vertebras,  and 
that  the  effect  of  the  pressure  of 
the  body  in  the  upright  position 
for  some  time  reduces  them 
more  than  one-fourth  of  their 
proper  size,  the  effect  of  lateral 
pressure  long  continued  is  readily 
appreciated — they  become  wedge- 
shaped  and  lose  their  elasticity  and  ability  to  return  to  a  normal  position. 

The  ligaments  connecting  the  vertebras  (especially  the  inter-transverse  and 
lateral)  and  connecting  the  ribs  to  the  vertebras  are  shortened  on  the  con- 


FiG.  3S0.— Scoliosis  in  Kentucky   Giant  (Specimen 
in  Philadelphia  College  of  Physicians). 


LATERAL  CURVATURE  OF  THE  SPINE. 


553 


cavity  and  lengthened  on  the  convexity  of  the  curve.  The  muscles  on  the  con- 
vexity are  relaxed,  fatty  degenerated,  and  atrophied,  and  on  the  concavity  con- 
tracted, but  altered  to  a  less  degree.  The  relations  of  the  long  dorsal  spina] 
muscles  are  stretched  and  lengthened  on  the  convex  side,  and  contracted  and 
shortened  on  the  concave. 

The  flat  muscles  adapt  themselves  to  the  changes — the  rhomboidei,  trape- 
zius, latissimus,  and  serratus  major  et  minor  being  thinned  and  atrophied  over 
the  bulging  parts,  and  shortened  and  thickened  over  the  depression. 

All  the  ligaments  of  the  body  are 
stretched  and  relaxed,  giving  rise  at  the 
knee  to  a  condition  of  back-knee,  and  in 


Fig.  381. — Specimen  of  Scoliosis  showing  Wedge- 
shaped  Formation  of  Vertebras  (Wistar  Institute 
of  Anatomy). 


Fig.    3S2. — Lateral    Curvature    showing 
Wedge-shaped  Bodies. 


the  elbow  to  the  condition  of  hyperextension  which  is  so  frequently  found  to  be 
associated  with  lateral  curvature. 

The  effect  of  lateral  curvature  is  to  cause  displacements  of  the  thoracic, 
abdominal,  and  pelvic  viscera.  The  lungs  are  compressed  on  the  side  of  the 
convexity,  and  the  heart  in  severe  cases  is  displaced  toward  the  concave  side. 
According  to  Adams,  scoliosis  leads  to  phthisis  or  a  phthisical  diathesis,  but  he 
admits  the  absence  of  statistics  to  prove  a  fact  also  contradicted  by  specialists 


554 


ORTHOPEDIC  SURGERY. 


upon  lung  disease,  who  may  not  see  these  cases,  since  the  writer  has  himself  lost 
cases  of  scoliosis  from  this  cause.  The  stomach,  intestines,  and  liver  are 
displaced  downward,  and  the  spleen  and  the  kidney  upon  the  convex  side  are 
usually  smaller  than  normal. 


■ 

r 

■ 

^ft  ■ 

H 

i 

1^1 

HI 

I^H 

Fig.  38,^. — Severe  Scoliosis  (Hirst), 
of  Anatomy.) 


(Wistar   Institute 


Fig.  3S4. — Same,  Laterai.  View  (Hirst).    (Wistar  Insti- 
tute of  Anatomy.) 


These  pathologic  changes  illustrate  the  results  of  the  faulty  position,  but 
contribute  little  evidence  as  to  the  real  etiology  of  the  affection.  The  theories 
proposed  are  very  numerous,  and  furnish,  as  Copeland  facetiously  remarks, 
material  for  a  keen  satire  on  the  medical  art;  but  the  theory  of  superincumbent 


LATERAL  CURVATURE  OF  THE  SPINE.  555 

weight  or  pressure  is  applicable  to  the  majority  of  cases,  and  is  the  one  now 
generally  accepted  by  writers. 

The  theories  may,  however,  be  included  under  five  heads:  the  muscular 
theory,  the  ligamentous  theory,  the  osseous  theory,  the  theory  of  unilateral 
development,  and  the  theory  of  pressure  or  superincumbent  weight. 

The  muscular  theory  of  unequal  primary  muscular  action  has  been  ad- 
vanced and  defended  from  time  to  time  by  a  host  of  writers.  The  idea  of  an 
active  muscular  contraction  identical  with  torticollis,  supported  by  Guerin  and 
others,  was  shown  to  be  based  upon  false  premises.  The  unilateral  relatively 
stronger  action  of  the  right  serratus  which  formed  the  basis  of  Stromeyer's 
respiratory  theory  has  been  sufficiently  refuted  by  the  absence  of  anatomic  and 
clinical  facts,  and  by  the  arguments  of  Werner.  The  modified  form  of  the  mus- 
cular theory  advanced  by  Eulenberg  has  much  to  recommend  it.  It  assumes 
that,  inasmuch  as  continuous  muscular  action  is  necessary  to  maintain  the  erect 
position,  if  any  muscle  be  weakened  the  spinal  column  will  tend  to  bend,  the 
convexity  falling  on  the  weaker  side,  overstretching  the  muscles  upon  this  side, 
and  if  continued  for  a  time  would  cause  permanent  distortion. 

Evidence  of  changed  electric  reactions  and  primary  weakness  of  the  muscles 
either  is  wanting  or  has  not  been  demonstrated  in  the  early  cases.  While  pri- 
mary muscular  relaxation  may  not  be  accepted  as  an  actual  cause,  its  im- 
portance as  a  predisposing  factor  in  static  cases  cannot  be  overestimated. 

Secondary  muscular  changes,  such  as  atrophy  due  to  degeneration  of  the 
cord,  or  as  the  result  of  a  disturbance  of  central  trophic  innervation,  are  accepted 
by  all. 

The  ligamentous  theory.  The  importance  of  the  intervertebral  ligaments 
in  the  etiology  has  never  been  appreciated.  The  highly  elastic  property  of  the 
yellow  elastic  tissue  which  composes  some  of  these,  especially  the  ligamenta 
subflava,  serves  to  preserve  the  erect  posture  and  to  restore  the  spine  after 
flexion.  In  static  cases  with  feeble  muscular  system,  when  the  spinal  column 
is  placed  in  the  attitude  of  rest  the  ligaments  sustain  almost  the  entire  weight 
and  gradually  yield  and  assume  a  curvature  in  the  direction  of  the  habitual 
position  of  the  patient.  This  condition  is  identical  with  that  which  occurs  in 
static  cases  of  knock-knee,  and  while  thorouglily  tenable  in  all  its  parts,  has  not 
receivedthe  support  of  authority. 

The  osseous  theory,  which  attributes  scoliosis  to  an  insidious  inflammatory 
softening,  the  patient  instinctively  assuming  a  lateral  position  to  avoid  pressure, 
has  been  maintained  by  some  observers.     Cases  are  rare  in  which  the  patho- 


556  ORTHOPEDIC  SURGERY. 

logic  findings  correspond  to  this  theory,  and  most  authorities  doubt  its  existence 
or  confound  lateral  curvature  with  lateral  deviation  in  Pott's  disease,  and  in 
scoliosis  the  cancellous  tissue  does  not  present  a  trace  of  inflammation  or  sclerosis. 
A  modification  of  the  osseous  theory  is  met  in  Hueter's  theory  of  symmetric 
pressure  from  growth  of  the  ribs.  Numerous  objections  have  been  raised 
against  this  theory,  and  Lorenz  and  others  have  proved  its  fallacy  by  the  dis- 
covery of  primary  osseous  deviations  of  other  vertebras,  the  absence  of  changes 
in  the  costal  cartilages,  the  inability  of  the  ribs  to  make  pressure  from  before 
backward  and  from  without  inward,  the  frequency  of  other  forms,  as  cervical 
and  lumbar,  and  from  the  absence  of  the  osseous  deformations  characteristic  of 
the  theory.  The  osseous  changes  occurring  in  scoliosis  can  all  be  accounted 
for  by  Wolf's  law. 

The  theory  oj  unilateral  development,  that  scoliosis  is  only  a  pathologic 
increase  of  what  is  physiologic,  has  been  supported  by  many  eminent  writers. 

According  to  most  anatomists,  the  spine  has  a  slight  lateral  curvature  about 
the  fourth  or  fifth  dorsal  vertebra,  the  convexity  of  which  is  directed  toward  the 
right  side,  being  produced  chiefly  by  muscular  action,  the  right  side  being  used  by 
most  persons  by  preference  to  the  left,  and  different  observers  having  found  in 
one  or  two  individuals  who  were  left-handed  the  lateral  curvature  directed  to  the 
left  side.  According  to  some,  scoliosis  results  from  an  exaggeration  of  this, 
which  others  considered  to  be  due  to  the  course  of  the  aorta,  while  others  attrib- 
uted it  to  the  more  rapid  growth  of  the  right  half  of  the  body  or  to  the  increased 
weight  of  the  organs  on  the  right  side. 

Albrecht  has  shown  that  the  right  upper  extremity  of  the  fetus  of  all  mam- 
mals has  a  better  blood-supply,  which  results  in  exaggeration  of  nutrition  and 
physiologic  dorsal  right  curvature.  If,  as  has  been  pointed  out,  it  is  not  certain 
that  the  right  dorsal  curvature  is  physiologic  in  youth,  if  also  we  consider  the 
frequency  of  primary  cervical  and  dorsal  curves  and  the  occurrence  of  left  sco- 
liosis in  persons  who  are  not  left-handed,  but  little  importance  can  be  accorded 
to  the  physiologic  theory  of  scoliosis. 

The  theory  of  pressure  or  superincumbent  weight,  which  assumes  the  gradual 
transformation  of  the  normal  spine  under  mechanical  influences  falling  obliquely 
upon  it  through  faulty  attitude,  is  accepted  by  most  authors  at  the  present  time, 
and  has  been  advocated  especially  by  Volkmann,  Roser,  and  others,  and  this  the 
writer  supports,  giving  especial  importance  to  the  ligaments  in  the  secondary 
changes  which  occur. 

Any  asymmetry  of  development  or  faulty  posture  which  causes  the  spine 


LATERAL  CURVATURE  OF  THE  SPINE. 


557 


to  deviate  from  the  median  line,  and  which  destroys  the  equilibrium  of  the  spinal 
column,  may  be  looked  upon  as  a  predisposing  cause,  and  the  superincumbent 

weight  of  the  body  as  the  direct  etiologic  factor  in 
the  production  of  this  affection. 

Clinical  History  and  Symptomatology. 

The  lateral  curvature  or  rotation  of  the 
vertebras  are  rarely  first  observed.  Usually  the 
dressmaker  or  tailor  discovers  an  inequality  of 
one  shoulder,  or  a  growing  out  of  one  hip,  and; 
these  being  further  investigated  by  the  surgeon, 
the  true  nature  of  the  affection  is  at  once  revealed. 


Fig.  385. — I^EFT  Lumbar  Scoliosis, 
SHOWING  I.ow  Shoulder  (Spel- 
lissy) . 


Fig.  386. — Right  Lumbar  Scoliosis,  Mild  Degree. 


In  girls  great  difficulty  is  experienced  in  fitting  waists,  plaid  goods,  sailor  collars, 
and  garments  that  are  turned  in  making.  They  may  be  easily  fatigued,  complain 
of  muscular  wealoiess,  and  be  disposed  to  recline  or  rest  much  of  the  time ;  or 


558 


ORTHOPEDIC  SURGERY. 


a  boy  complains  of  one  suspender  shoulder-strap  constantly  slipping,  or  one 
trouser  leg  wearing  out  at  the  bottom,  or  a  girl  of  her  inability  to  keep  the 
shoulder-straps  in  position  or  to  have  her  skirts 
made  even  on  both  sides.  In  some  a  limp  is 
noticeable  and  others  walk  in  a  sideways  manner. 
This  should  at  once  direct  attention  to  the  spine, 
and  in  slight  cases  the  following  changes  will  be 
noted : 

In  one  of  the  most  common  varieties — the  left 
primary  lumbar  curvature — the  waist-line  on  the 
left  is  flattened  or  obliterated,  and  on  the  right 
deepened,  and  the  waist-angle  rendered  more  acute. 


Fig.  3S7. — Severe  Dorso-lumear  Lateral  Curvature. 


Fig.  388. — Left  I,umbar  Scoli- 
osis, SHOWING  High  Hip  (Spel- 
lissy). 


The  crest  of  the  right  hip  becomes  more  promment,  and  the  crest  of  the  left 
disappears.     From  a  rotation  of  the  vertebras  the  left  lumbar  resfion  becomes 


LATERAL  CURVATURE  OF  THE  SPINE. 


559 


fuller,  and  the  right  flattened.  Later,  as  the  compensatory  dorsal  curve  forms, 
the  body  placed  in  Adams'  position  (strongly  flexed  forward)  reveals  the  ser- 
pentine course  of  the  spinous  processes,  and  the  erector  spinse  mass  of  muscles 
is  flattened  on  the  left  from  the  deviation  forward  of  the  transverse  processes. 

In  this  form,  as  in  almost  all  cases  of  scoliosis,  the  first  curve  is  Icnovm  as 
the  primary  curve,  to  distinguish  it  from  the  other  curves  which  afterward  form, 
and  which  are  distinguished  as  secondary  or  compensatory  curves. 

Right  convex  dorsal  scoliosis,  very  frequently  a  primary  affection,  gives 
symptoms  still  more  pronounced.  In-  the  slight  cases  the  ribs  on  the  right  side 
are  more  prominent,  the  scapula  projects  slightly  backward,  the  left  hip  is  a 


-Left  Lumbak  Scoliosis.     First 
-Right  Shouxdek  Depressed. 


Fic.  390. — Same,  Second  Stage — Right  SHOtrL- 
DER  Elevated. 


little  more  prominent,  and  spinous  processes  in  Adams'  position  are  curved 
slightly  (convexly)  to  the  right.  In  right  dorsal  curvature  secondary  to  left 
lumbar  scoliosis  the  position  of  the  shoulders  differs  at  different  periods  of  the 
deformity.  During  the  first  stage  the  right  shoulder  is  depressed,  but  later 
when  the  compensatory  curve  becomes  more  marked  the  left  shoulder  becomes 
depressed  and  the  right  shoulder  is  elevated.  In  severe  cases  these  changes  are 
increased  and  augmented  by  others. 

The  right  costal  angle  is  increased  in  extent  and  prominent,  and  the  left 
flattened  and  decreased.  The  conformation  of  the  anterior  part  of  the  chest  is 
affected,  but  to  a  less  degree  than  the  posterior,  and  the  breasts  are  unsym- 


560 


ORTHOPEDIC  SURGERY. 


metrically  placed,  the  left  being  usually  more  prominent  and  higher.  The  ab- 
domen is  less  prominent  on  the  left,  and  the  umbilicus  is  displaced  to  one  side. 
The  left  scapula,  more  prominent,  is  elevated  and  projected  backward,  while 
the  less  prominent  left  scapula  approaches  the  median  line  and  is  flat- 
tened.    With  the  formation  of  a  secondary  compensating  lumbar  curve,  the 

alterations  before  de- 
scribed under  primary 
left  lumbar  scoliosis  are 
superadded.  And  later, 
with  the  formation  of  a 
compensatory  left  convex 


Fig.   391. — Right  Dorsal   Sco-      Fig.   392. — Right    Dors.\l  Sco-      Fig.  ,-,93. — Left  DoRs.Ai  Scolio- 
Liosis,   Mild    Degree    (Spel-  liosis,  Severe  Degree  (Spel-  sis,  Severe  Degree,  in  a  Boy 

lissy).  lissy).  (SpelUssy). 


cervical  curve,  the  outline  of  the  shoulder  and  neck  is  altered,  and  the  normal 
beautifully  curved  shoulder-line  is  changed;  it  is  more  curved  on  the  right, 
the  shoulder  more  prominent,  the  neck  longer;  on  the  left  it  is  flattened,  the 
shoulder  is  less  rounded,  and  the  neck  shorter. 

The  exact  process  by  which  a  cervical  curvature  from  Avry-neck  induces 
a  lateral  curvature  of  the  entire  column  is  interesting.     The  deviation  of  the 


LATERAL  CURVATURE  OF  THE  SPINE. 


561 


head  to  one  side  and  the  flexion  of  the  chin  upon  the  thorax  by  the  unilateral 
contraction  induce  a  bowing  of  the  cervical  vertebras  to  that  side  and  rotation 
of  the  bodies  upon  one  another.  There  is  at  once  produced  a  characteristic 
alteration  in  the  outline  of  the  neck — the  graceful  double  curve  becomes  flat- 
tened, the  neck  shortened,  and  the  shoulder  less  prominent  on  the  one  side, 
while  the  curved  line  becomes  more  pronounced,  the  neck  longer,  and  the  shoul- 
der more  prominent  on  the  other  side. 

The  natural  balance  of  the  column  being  disturbed,  Nature  endeavors  by 


Fig.  394. — Right  Dorsal  Scoliosis.     Adams'  Position,  showing  Rotation. 


a  compensatory  dorsal  curve  to  restore  the  equilibrium.  This  induces  a  rota- 
tion of  the  bodies  of  the  dorsal  vertebras  with  aU  its  attendant  deforming  features: 
the  flattening  and  twisting  of  the  scapula  on  one  side,  the  deviation  of  the  spinous 
processes  in  a  serpentine  durection  from  the  median  line,  and  the  elevation  and 
projection  backward  of  the  scapula  on  the  other  side.  With  the  development 
of  a  third  or  lumbar  curve  the  crest  of  the  hip  becomes  obliterated  on  one  side, 
the  waist-line  deepens,  the  hip  becomes  prominent  on  the  other  side,  and  the 
lateral  outlines  become  everywhere  less  symmetric. 

It  is  popularly  believed  by  the  superstitious  that  persons  suffering  from 


562  ORTHOPEDIC  SURGERY. 

lateral  curvature  possess  great  intelligence,  bad  tempers,  and  intense  venereal 
capabilities.  Though  these  qualities,  for  obvious  reasons,  are  more  or  less 
frequently  associated  with  tuberculous  caries  of  the  vertebras,  they  do  not 
apply  to  sufferers  from  lateral  curvature,  who  in  other  respects  seldom  differ 
from  healthy  individuals. 

In  severe  cases,  in  addition  to  the  inconvenience  and  discomfort  of  the 
lateral  deformity,  actual  pain  in  different  parts  of  the  spine — occasionally 
referred  to  the  peripheral  distribution  of  the  spinal  nerves  from  intervertebral 
pressure — and  thorax  from  nervous  pressure  may  be  experienced;  and  dyspnea, 
emphysema,  catarrhal  bronchitis,  pneumonia,  and  palpitation  of  the  heart  may 
be  complained  of.  In  patients  under  twelve  years  of  age  chorea  has  been 
observed  by  the  writer.  Venous  stasis  in  the  extension  vascular  system  of  the 
spinal  canal  is  responsible  for  the  occipital  headache  and  neuralgias  which  are 
so  constant,  as  well  as  for  the  menstrual  disturbances  which  form  an  integral 
part  of  the  symptomatology  of  this  affection.  The  digestion  may  be  impaired, 
the  appetite  capricious,  and  the  patient  nervous  or  neurasthenic;  whUe,  on  the 
other  hand,  aside  from  the  deformity,  they  may  occasionally  enjoy  compara- 
tively perfect  health. 

Three  stages  of  the  affection  may  be  distinguished : 
First  stage,  or  initial  stage. 
Second  stage,  or  stage  of  development. 
Third  stage,  or  stage  of  arrest. 

The  first  stage  in  ordinary  juvenile  cases  extends  from  the  beginning  of  the 
affection — from  the  sixth  to  the  twelfth  year — to  puberty;  the  second  stage 
from  puberty  until  the  nineteenth  to  twenty-first  year,  the  period  of  the  establish- 
ment of  growth;  and  the  third  stage  includes  the  period  after  the  completion 
of  the  developmental  age. 

Diagnosis. 

The  importance  of  a  correct  early  diagnosis  cannot  be  overestimated,  since 
it  is  the  early  stages  which  offer  the  most  hope  of  perfect  restoration.  The  ex- 
amination should  be  conducted  in  a  good  light,  and  the  contour  and  outlines 
of  the  trunk  should  be  examined  from  different  positions  in  front  and  behind. 
For  this  purpose  the  patient,  if  a  child,  should  be  freely  exposed  to  below  the 
trochanters,  and  the  clothing  conveniently  secured  by  means  of  an  ordinary 
roller  bandage.  The  relation  of  the  spinous  processes  should  be  carefully 
observed  and  marked  while  the  patient,  standing  erect,  bends  far  forward  until 


LATERAL  CURVATURE  OF  THE  SPINE.  563 

the  trunk  is  horizontal  (Adams'  position),  or  practises  self-suspension  from  a 
bar  or  Sayre  apparatus.  The  inequality  of  the  lower  extremities  may  be  tested 
by  thin  boards  or  books  placed  under  the  feet,  or  with  the  author's  machine 
for  measuring  inequality,  described  under  unilateral  development,  while  a  rule 
or  spirit-level  estimates  the  amount  of  obliquity  of  the  iliac  spines.  If  doubt 
exists,  or  any  inequality  be  discovered,  the  upper  part  of  the  body  may  be 
covered,  and  upon  a  hard  couch  the  exact  measurements  of  the  lower  extremi- 
ties from  the  anterior  superior  spinous  processes  or  umbilicus  be  taken. 

Mensuration  and  Recording  Methods. — Many  methods  have  been  devised 
for  measuring  and  recording  the  amount  of  deformity,  by  means  of  more  or  less 
complicated  apparatus,  of  which  I  have  recently  collected  a  table  including  no  less 
than  68  appliances  of  various  forms,  as  follows : 

TABLE  OF  SCOLIOSOMETRY. 

I.  Pliable  reproduction, (i)  Plaster  Cast.     (Delpech;  Heine.) 

(2)  Model  Bandage.     (Beely.) 

(3)  Bas  Relief. 

(4)  Segmentary  Plaster  Strip  Impression.     (DoUinger.) 

(5)  Plate  Moulding.     (Hubscher.) 

II.  Perspective  drawing, (i)  Freehand  drawing. 

(2)  Photography. 

Plain.     (Berend.) 

Screen.     (Spellissy;  Young;  Hovorka.) 

Roentgen  Ray.     (Kraus;  Kienback.) 

Stereoscopic.     (Schanz.) 

Radiography.     (Hoffa;  Baer.) 

Screen  Radiography.     (Joashimsthal.) 

Orthodiagraphy. 

III.  Measuring, (r)  Simple  Measuring  of  the  Body. 

Measuring  Band.     (Schanz;  Sargent.) 
Calipers.     (Schulthess;  Reiner.) 
Leveling  Trapeze.     (Schulthess.) 
Spirit"  Level. 
Water  Level. 
Glass  Tubes. 

Pendulum  Rod.     (Heinecke.) 
Plummet.     (Buhrings.) 
(2)  Outside  Measuring  of  the  Body. 
PUable  Metal  Band. 

Scoliosometer.     (Mikulicz;  Beely-Kirchoff.) 
Simple  Co-ordination  Apparatus.     (Weil;  Pansch.) 
Measuring  Apparatus.     (Biggs.) 
Diastropometrie.     (Roberts.) 
Scoliosometer.     (Zander;  Bradford.) 

iV.  Profile  drawing (i)  General  Surface  Measuring. 

Cyrtometer.     (Voillez.) 
Lead  Strip.     (Schildbach.) 


564 


ORTHOPEDIC  SURGERY. 


TABLE  OF  SCOLIOSOMETRY— (Co«/Jw«erf). 


Profile  drawing, — {Conlinued.) . 


.{2)  Special  Surface  Measuring. 
Tin  Strip.     (Roth.) 

Rod  Cyrtometer.     (Beely;  Elkinton-Young;  Murray.) 
Glass  Plate.     (Buhrings;  Milo;  Ghillini;  Lange.) 
Camera  Obscura.     (Schildbach.) 
Camera  Lucida.     (Wollaston;  Epper;  Grunbaum.) 
Silhouette.     (Theslow.) 
Notograph.     (Virchow;  Elkinton-Young;  Seeger;  Murray; 

Weigel;  Rausch.) 
Scoliosis  Gauze.     (Barwell.) 
Scoliosometer.     (Schulthess.) 

Thoracograph.     (Socin  and  Burkart;  Schenk;  Hubscher.) 
Tachygraph.     (Beondetti;  Scudder;  Walther.) 
Pantograph.     (Hall.) 
Thoracometer.     (Heinleth.) 


This  table  I  have  corrected  from  Hovorka  and  Hoffa,  and  it  includes  all 
methods  of  measuring  from  the  simplest  freehand  drawing  to  the  most  elabo- 
rate and  precise  mathematical  instruments. 

The  ordinary  cyrtometer  used  by  clinicians  to  measure  the  chest,  or  an  or- 
dinary lead  measure  with 
freehand  sketching,  has  been 
found  by  the  writer  to  answer 
all  practical  purposes,  but  for 
scientific  records  more  accu- 
rate measurements  are  avail- 
able. 

The  taking  of  plaster 
casts  of  the  body  is  tedious  and 
cumbersome.  The  camera  ob- 
scura reproduces  only  a  por- 
tion of  the  deformity,  and  pho- 
tographic reproductions  are 
variable,  for  obvious  reasons, 
so  that  mechanical  devices 
offer  the  best  means  of  illus- 
trating the  deviations. 
The  methods  most  frequently  employed  are  the  lead  measuring  strip,  the 
cyrtometer,  freehand  drawing,  photography,  McLaren's  measurements,  Weigel's 
trolley  machine,  and  Beely's  scoliosometer.  Of  these,  the  cyrtometer  is  simple 
and  reliable,  and  Beely's  scoliosometer  is  satisfactory,  but  could  be  improved 
by  attaching  it  to  a  table.     The  most  satisfactory  methods  at  the  present  time 


Fig.  395. — Scoliosometer  of  Zander. 


LATERAL  CURVATURE  OF  THE  SPINE. 


565 


are  Sargent's  anthropometrical  measurements,  photography  through  a  screen, 
Bradford's  scoliosometer,  and  the  Elkinton- Young  improved  trolley  delineator 
and  rod  scoliosometer. 

1.  Sargent's  Charts. — The  advantages  of  this  system  of  measurements 
are  that  they  give  not  only  the  average  measurements  for  the  given  age  and  weight 
of  the  individual,  but  the  two  sides  of  the  body  may  be  compared  and  any 
defect  or  unilateral  development  may  be  readily  detected. 

2.  Photography  through  a  Screen. — By  this  method  a  photograph  may 


Fig  396. — Improved  Trolley  Delineator,  Vertical 
Position. 


Fig.  397. — Improved  Trolley  Delineator,  Horizon- 
tal Position. 


be  taken  through  a  screen  made  of  threads,  or,  first,  lines  may  be  made  upon 
sensitized  paper,  and,  second,  the  patient  photographed  upon  the  same  paper, 
as  devised  by  Spellissy.  Photography  of  this  kind  requires  that  the  position  of 
the  stand,  screen,  and  patient  shall  remain  unchanged,  and  each  subsequent 
picture  be  taken  in  the  same  manner.  I  have  rendered  the  screen  more  useful 
by  indicating  the  central  cross-section  by  a  knot  or  two  oblique  threads.  This 
point  being  placed  exactly  opposite  the  sixth  dorsal  vertebra,  or  on  a  corre- 
sponding point  of  the  front  of  the  body,  to  be  located  with  the  spirit-level.     It  is 


566 


ORTHOPEDIC  SURGERY. 


also  advisable  to  mark  upon  the  body  with  a  skin  pencil  the  spinous  pro- 
cesses of  the  scapula,  the  spinous  processes  including  the  natal  cleft,  and 
to  draw  a  line  between  the  posterior  spinous  processes.  The  intersections 
of  this  line  with  the  line  marking  the  spinous  processes  will  make  a  cross 
which  will  enable  the  eye  clearly  to  note  any  deviation  of  the  pelvis. 

Spellissy  has  proposed  a 
uniform  photographic  method 
which,  if  adopted,  would  be 
of  great  service  in  provid- 
ing practically  identical  con- 
ditions for  all  who  are  en- 
gaged in  this  work.  He 
has  recommended  the  use 
of  a  double  print,  taking 
as  a  standard  for  the  squares 
one  twenty-fourth  of  the 
stature,  which  is  a  conve- 
nient size  both  for  record  and 
comparison.  This  standard 
of  measurement  could  be 
secured  if  those  interested  in 
the  subject  could  agree  upon 
the  following: 

"i.  A  standard  focal 
length  of  lens; 

"  2 .  A  standard  focus  and 
distance  of  subject  from  lens 
front ; 

"3.  A  standard  direction 
of  lighting  for  recording  pur- 
poses; 

"4.  A    standard   size  of 
image  and  of  division  of  chart  for  comparative  illustrations;  and 

"5.  A  standard  series  of  poses  in  faulty  habitual  andjalso  in  corrected 
postures,  standing,  recumbent,  and  suspended;  then  the  records  of  different 
observers  would  permit  accurate  comparison." 

3.  Bradford's   Scoliosometer. — This  instrument   is  the   most   accurate 


Fig.  398  —  Scoliosometer  of  Schtjlthess. 


LATERAL  CURVATURE  OF  THE  SPINE. 


567 


device  for  measuring  for  the  degree  of  the  deformity  due  to  rotation  of  the 
bodies  of  the  vertebra.  It  consists  of  two  arms,  a  scale,  and  a  spirit-level.  It  is 
placed  on  the  body  with  the  two  arms  together,  and  the  rod  containing  the 


f  Transverse  Diameter  of  Pedestal  and  1 


Posterior  Plane  in  Vievv 


n Transverse  Axis 
3j  Inches  = 
Working  Rule. 


Fig.  399. — Uniform  Photographic  Method  (Spellissy). 


spirit-level  is  elevated  until   the  horizontal  is  reached,  when  the  degree  may 
be  read  off. 

4.  The  Improved  Trolley  Delineator.— This  is  an  improvement  on  the 


568  ORTHOPEDIC  SURGERY. 

Weigel  machine,  and  is  so  arranged  that  the  outlines  may  be  taken  in  the  vertical 
and  horizontal  planes.  The  paper  is  on  a  continuous  roll,  and  the  tracing  may 
be  taken  either  with  a  wheel  or  a  point.  In  either  case  the  personal  element 
enters  into  the  taking  of  outlines. 

5.  Rod  Scoliosometer. — This  method  is  not  unlike  the  scoliosometer  of 
Beely,  but  it  has  one  advantage,  in  that  it  is  attached  to  an  upright.  Two  points 
upon  the  spine,  the  seventh  cervical  vertebra  and  the  top  of  the  coccyx,  are 
fixed  against  two  rods  of  the  machine,  against  which  the  patient  leans.  The  rods 
are  pushed  in  singly  and  marked  upon  the  chart.  Any  deviation  is  indicated 
upon  the  chart  which  has  square  tracings  upon  it. 

For  the  complete  bibliography  of  scoliosometry  see  Hovorka,  "  ^littheil- 
ungen  der  anthropologischen  Gesellschaft,"  Wien,  1904,  Bd.  xxxiv. 

The  three  stages  or  degrees  of  deformity  should  be  carefully  separated,  as 
these  bear  directly  upon  the  prognosis. 

In  the  first  degree,  the  curvature  can  be  readily  restored  by  suspension, 
lying,  or  slight  manual  pressure. 

In  the  second  degree,  the  curoature  cannot  be  entirely  restored  by  these 
measures. 

In  the  third  degree,  the  cm-vattire  cannot  be  affected  in  the  least  by  these 
measures. 

In  this  connection,  particular  attention  should  be  directed  to  those  cases 
of  so-called  lateral  bending  of  the  spine  occurring  in  all  classes  and  conditions 
of  youth  from  general  debility,  in  w^hich  the  spine,  though  much  deformed  lat- 
erally, is  without  rotation  of  the  bodies  of  the  vertebras,  and  can  usually  be 
restored  by  effort  of  the  patient,  who  is  quickly  relieved  by  attention  to  the  gen- 
eral health.  Lateral  deviation  of  the  spine  occurring  in  Pott's  disease  may  be 
confusing  in  the  early  stage.  From  Pott's  disease  of  the  spine  the  differential 
diagnosis  will  be  found  under  the  appropriate  section. 

Diagnosis  in  Individual  Forms.— Every  case  of  lateral  curvature  re- 
quires individual  study,  as  no  two  cases  are  exactly  alike.  The  diagnosis  of 
the  individual  forms  is  also  important  and  should  be  made  at  this  time.  The 
most  common  of  all  and  the  most  easily  recognized  will  be  the  habit  scoliosis. 
Very  frequently  children  suft'ering  from  this  form  of  lateral  curvature  stand 
in  an  attitude  which  is  characteristic  and  which  may  be  readily  recognized. 
The  patient  stands  upon  one  foot  with  the  other  limb  slightly  flexed  and  thrust 
forward.     The  lateral  curvatures  which  are  due  to  rickets,  but  which  rarelv 


LATERAL  CURVATURE  OF  THE  SPINE.  569 

occur,  however,  may  be  recognized  from  the  association  of  other  symptoms 
characteristic  of  the  rachitic  condition. 

Lateral  curvature  due  to  empyema  may  frequently  be  recognized  by  the 
inspection  of  the  chest,  but  the  previous  history  will  be  of  great  service  in  dis- 
tinguishing this  condition  from  similar  conditions  due  to  paralysis.  The  phys- 
ical signs  in  the  chest  will  be  of  great  service  also  in  determining  the  condition 
of  the  lungs  and  pleurae,  and  should  have  direct  bearing  upon  the  treat- 
ment. 

The  paralytic  forms  of  lateral  curvature  are  very  frequently  due  to  infantile 
spinal  palsy.  These  are  usually  produced  in  two  ways — first,  from  the  paralysis 
of  the  muscles  of  the  back,  and  also  from  the  paralysis  of  one  lower  extremity, 
producing  the  static  condition. 

Traumatism  as  a  cause  for  lateral  curvature  is  very  unusual,  but  I  have 
occasionally  seen  patients  suffering  from  lateral  curvature  resulting  from  a 
severe  injury  of  the  attachment  of  the  ribs  to  the  vertebras  which  gradually 
developed  into  a  dorsal  scoliosis  associated  with  kyphosis  due  to  Pott's  dis- 
ease. 

Lateral  curvature  from  neuromuscular  changes — scoliosis  neuromuscularia 
ischiadica — should  be  diagnosed  as  early  as  possible.  The  history  of  exposure 
to  sudden  extreme  ranges  of  temperature;  the  attitude  of  the  patient  with  the 
entire  body  inclined  to  one  side ;  the  sciatic  pain  and  muscular  tenderness  over 
the  concavity  of  the  spine,  the  gluteal  region,  and  extending  down  the  limb, 
are  all  characteristic  of  the  acute  affection.  The  later  diagnosis  will  be  more 
difficult,  but  assistance  will  be  rendered  through  the  previous  history  of  the 
case. 

Differential  Diagnosis. — The  two  affections  with  which  lateral  curvature 
is  most  frequently  confounded  are  lateral  bending  of  the  spine  and  lateral  devia- 
tion of  the  spinous  processes.  Lateral  bending  of  the  spine  is  a  very  common 
condition  in  youth,  and  is  due  to  general  relaxation.  The  spine  is  deformed 
laterally  but  without  rotation  of  the  bodies  of  the  vertebras.  The  bending  can 
be  readily  overcome  by  pressure  with  the  hand  or  by  the  voluntary  effort  of  the 
individual,  and  may  be  very  soon  recovered  from  by  the  administration  of 
tonics  and  the  use  of  massage.  This  dift'ers  from  the  first  degree  of  lateral  cur- 
vature. Math  which  it  might  be  confounded,  in  this  respect,  that  no  changes  have 
yet  occurred  in  the  intervertebral  disks. 

Lateral  deviation  of  the  spinous  processes  occurs  in  Pott's  disease  during 
the  exacerbation,  the  deformity  being  produced  by  unilateral  muscular  spasm. 


570  ORTHOPEDIC  SURGERY. 

The  deviation  is  limited  to  a  very  few  vertebras  in  the  region  of  the  kyphosis.  It 
passes  very  quickly  when  the  patient  is  confined  in  the  prone  position,  and  should 
not  be  confounded  with  lateral  curvature  on  account  of  the  pressure  of  the 
kyphosis  and  the  other  symptoms  characterstic  of  Pott's  disease. 

Another  affection  with  which  lateral  curvature  is  very  frequently  con- 
founded is  Pott's  disease  itself.  If  the  characteristic  symptoms  of  this  disease 
are  carefully  studied,  error  in  the  diagnosis  will  very  rarely  occur.  The  most 
important  characteristic  is  the  posterior  deformity,  which  is  in  the  median 
line  of  the  body,  is  sharply  angular  in  character,  and  is  not  affected  by 
suspension. 

In  rickets  of  the  spine  the  deformity  is  usually  a  posterior  one,  the  curve  is 
very  long,  is  in  the  median  line,  and  other  symptoms  of  rickets  are  present  in  the 
individual. 

In  sacro-iliac  disease  the  attitude  of  the  patient  might  lead  to  an  error  in 
the  diagnosis,  the  body  being  held  to  one  side;  but  the  pain,  swelling,  and 
other  inflammatory  symptoms  in  the  region  of  this  joint  would  quickly  lead 
to  a  correct  diagnosis  of  the  condition. 

In  lumbago  and  sciatica  the  acute  nature  of  the  affection,  the  prominence  of 
pain  as  a  symptom,  and  the  absence  of  a  marked  curve,  would  readily  dis- 
tinguish this  condition. 

Sarcoma  of  the  spine  would  not  at  first  be  considered  an  afl'ection  which 
might  be  confounded  with  lateral  curvature  of  the  spine,  and  yet  the  writer  has 
observed  cases  of  persons  past  middle  life  suffering  from  severe  lateral  curvature 
in  the  lumbar  region  and  accompanied  by  intense  pain,  which  for  some  time 
appeared  to  be  a  malignant  affection,  but  which  was  later  found  to  be  a  lateral 
curvature  of  the  spine. 

Progress  and  Prognosis. 

The  progress,  unless  early  arrested,  is  usually  unfavorable;  but  the  afl'ec- 
tion may  be  spontaneously  arrested  or  become  stationary  at  any  stage.  In  the 
first  degree,  persistent  and  well-directed  measures  will  permanently  and  surely 
restore  the  symmetry;  in  the  second,  the  affection  may  with  a  degree  of  certainty 
be  arrested,  and,  especially  in  primary  lumbar  scoliosis,  be  much  improved,  or 
even  cured;  but  in  the  third  stage  nothing  can  be  accompHshed  toward  restoring 
the  function  of  the  spinal  column,  and  measures  must  be  directed  to  concealment 
of  the  deformity. 

It  has  been  asserted,  but  without  positive  proof,  that  scoliotic  patients  are 


LATERAL  CURVATURE  OF  THE  SPINE.  571 

short-lived — heart  lesions  and  apoplexy  being,  according  to  Bouvier,  the  most 
frequent  causes  of  death.  The  dangers  of  parturition  in  scoliotic  women  are 
unfounded,  except  when  the  degree  is  of  the  highest  grade,  or  rachitic  deformity 
of  the  pelvis  coexists. 

Prophylaxis. 

It  is  important  that  the  attitude  in  sitting  should  be  correct,  since  so 
many  deformities  of  the  spine  are  the  result  of  faulty  attitudes  assumed  in  the 
sitting  position. 

The  history  of  reform  in  school  furniture  in  this  country  dates  back  to 
1848,  when  Barnard  published  an  article  upon  "School  Architecture";  and 
abroad  it  was  even  later,  1865,  when  Fahrner,  of  Zurich,  gave  the  result  of  his 
studies  in  "Das  Kind  und  der  Schultisch."  The  anatomic  and  physiologic 
factors  were  worked  out  by  Meyer,  of  Zurich,  two  years  later,  and  about  the 
same  time  Cohn  discussed  the  subject  from  the  eye  specialist's  point  of  view. 
Stafifel,  1884,  Schenk,  1886,  Lorenz,  1888,  and,  more  recently,  Schulthess,  have 
made  valuable  additions  to  the  literature  upon  this  subject,  aU  of  them,  for  the 
most  part,  considering  the  problem  of  back-rests  as  a  factor  of  importance  in 
the  production  of  lateral  curvature.  But  the  Germans  have  been  much  ham- 
pered by  clinging  to  wooden  benches  for  two  or  more,  instead  of  individual 
seats  of  iron  or  wood. 

It  is  now  a  generally  admitted  fact  that  badly  designed  school  furniture 
is  frequently  the  cause  of  round  shoulders,  spinal  curvature,  and  short-sighted- 
ness; and  in  the  effort  to  remedy  this  evil  there  have  been  probably  150  different 
styles  devised. 

What  is  known  as  the  "balanced  sitting  position"  with  the  feet  resting 
firmly  upon  the  floor  and  the  knees  bent  at  right  angles  with  the  body,  is  the 
one  which  school  furniture  should  be  designed  to  maintain.  This  means  that 
the  weight  in  sitting  is  balanced  on  the  ischial  tuberosities.  To  keep  the  body 
in  this  position  as  nearly  as  possible  requires  (i)  a  suitable  and  convenient 
height  of  the  desk,  (2)  a  support  for  the  lower  part  of  the  back  in  writing  as  well 
as  in  reading,  (3)  proper  height  from  the  floor,  and  (4)  proper  distance  between 
the  desk  and  the  edge  of  the  seat.  The  support  for  the  lower  part  of  the  back 
is  especially  important,  as  it  brings  out  the  normal  physiologic  curves.  This 
support  may  be  continued  up  to  the  lowest  point  of  the  shoulder-blades,  or  a 
separate  upper  back-rest  may  be  used. 

A  great  deal  has  been  written  about  positive,  negative,  and  nil  distance 


572  ORTHOPEDIC  SURGERY. 

between  a  vertical  line  dropped  from  the  edge  of  the  desk  and  the  edge  of  the 
seat,  the  positive  distance  meaning  that  the  edge  of  the  seat  is  behind  the  ver- 
tical line,  the  negative  distance  meaning  that  the  edge  of  the  seat  is  in  front  of 
the  vertical  line,  and  the  nil  distance  meaning  that  the  edge  of  the  seat  exactly 
meets  the  vertical  line.  It  is  important  to  understand  these  terms  because  the 
positive  distance  is  generally  considered  to  be  the  proper  one  for  reading,  and 
the  negative  distance  for  WTiting. 

Certain  definite  rules,  some  general,  some  relative  to  the  individual,  may  be 
given,  as  compiled  from  various  authorities,  as  follows: 

1.  (a)  The  height  of  the  seat  shall  be  the  distance  of  the  bend  of  the  under 
side  of  the  knee  from  the  floor. 

(b)  The  width  of  the  seat  shall  be  a  trifle  wider  than  the  buttocks. 

(c)  The  length  of  the  seat  shall  be  two-thirds  the  length  of  the  thigh. 
{d)  The  seat  should  slope  slightly  down  and  back  about  three-eighths 

of  an  inch. 

2.  (a)  The  back-rest  should  be  at  an  angle  of  loo  to  no  degrees  with 
the  seat. 

{h)  The  back-rest  should  give  especial  support  to  the  lower  part  of  the 
back,  about  the  region  of  the  third  or  fourth  lumbar  vertebras. 

3.  (a)  The  height  of  the  desk  above  the  seat  should  be  equal  to  the  dis- 
tance from  the  olecranon  of  the  bent  arm  to  the  seat,  with  two  inches  added, 
or  one-eighth  the  height  of  a  girl  and  one-seventh  the  height  of  a  boy. 

(b)  The  slope  of  the  desk  should  be  about  15  degrees  for  writing  and 
30  degrees  for  reading. 

As  may  be  readily  seen,  all  these  conditions  cannot  be  fulfilled  by  fi.xed, 
immovable  desks  and  chairs,  and  we  therefore  now  come  to  the  consideration 
of  adjustable  furniture.  Dr.  Cotton,  of  Boston,  who  has  investigated  this  sub- 
ject of  school  furniture  at  the  request  of  the  Board  of  Schoolhouse  Commis- 
sioners, gives  the  following  requirements  of  adjustable  furniture: 

1.  Adjustment  for  height — vertically — of  chair. 

2.  Adjustment  for  height — vertically — of  desk. 

3.  A  back-rest  of  proper  inclination  with  an  adequate  support  for  the 
lower  part  of  the  back. 

4.  A  proper  depth  of  seat. 

5.  A  proper  slope  of  seat. 

6.  An  adjustment  of  desk  or  chair  for  plus  or  minus  distance — positive 
or  nesrative. 


LATERAL  CURVATURE  OF  THE  SPINE. 


573 


The  Milkr  chair  was  the  one  which  best  met  these  requirements  until  Cot- 
ton's experiments  produced  the  desk  and  chair  now  used  in  certain  Boston 
school-rooms.  The  essential  features  of  the  Miller  chair  are  adjustment  of 
the  seat  back  for  slope,  with  a  spring  attachment,  and  the  rocking  double  back- 
rest. Cotton's  model,  which  has  been  used  with  great  satisfaction,  consists  of 
a  curved  back  of  wood,  gf  inches  wide  and  5  inches  high,  with  a  concavity  of 


Fig.  400. — School  Seat  of  E.  Kuffel. 


Fig.  401. — School  Seat  of  Schreiber  and  Kline. 


Fig.  402. — School  Seat  of  Wackenroder. 


I  inch  from  side  to  side  and  a  convexity  of  i  inch  in  profile.  About  one-third 
the  way  up  is  the  greatest  convexity,  which  when  adjusted  comes  about  opposite 
the  fourth  lumbar  vertebra.  Two  sizes  of  these  seats  have  been  manufactured, 
some  of  them  adjustable  also  for  plus  and  minus  distance,  but  this  last  feature 
is  not  so  satisfactory  as  the  others. 

After  the  new  furniture  is  installed  the  first  adjustment  is  made  by  a  scale 


574  ORTHOPEDIC  SURGERY. 

and  by  certain  definite  rules,  but  there  are  always  some  pupils  who  cannot  be 
fitted  in  this  way,  and  for  these  an  individual  adjustment  is  made  by  an 
expert. 

The  problem  of  varying  the  distance  to  the  positive,  negative,  or  nil,  is  a 
vexed  one,  and  one  which  is  more  difficult  in  practice  than  in  theory.  Various 
methods  have  been  devised  for  securing  this  distance,  for  example,  the  sliding 
desk  top  of  E.  Kiiffel,  Schenk,  and  Chandler,  the  folding  desk  top  of  Parow, 
Schlimp's  desk  top  on  parallelogram  supports,  the  seat  swinging  on  a  vertical 
pin,  of  V.  Esch,  and  the  seat  swinging  on  parallelogram  supports,  of  Schreiber 
and  Kline,  also  the  sliding  seat  of  Wackenroder.  For  use  in  private  families 
the  chair  and  desk  devised  by  Clarke  meet  most  of  the  requirements,  but  the 
fact  of  both  being  movable  renders  this  device  unsuitable  for  large  class- 
rooms. 

The  practical  difficulty  in  the  employment  of  furniture  adjusted  to  distance 
is  that  it  is  either  very  expensive  or  is  noisy  in  its  operation,  so  that  even  when 
provided  it  is  not  often  used. 

Malposture  as  a  cause  of  lateral  curvature  has  been  considered  by  Gould,* 
who  ascribes  it  chiefly  to  the  fact  that  the  individual,  in  the  effort  to  bring  the 
writing  field  into  a  clearer  line  of  vision  with  the  "dominant"  or  right  eye, 
"skews"  the  paper,  tilts  the  head  to  the  left,  and  bends  the  body  to  the  left  also. 
This  bending  of  the  head  to  the  left  causes  a  right  cervical  curve  and  is  the  pri- 
mary factor  in  the  production  of  the  scoliosis,  the  curves  resulting  in  the  right 
dorsal  and  left  lumbar  regions  being  secondary  and  compensatory.  Any 
habitual  torsion  or  rotation  of  the  head  will  cause  a  corresponding  torsion  of 
the  body,  and  if  the  line  of  vision  be  defective  the  effort  to  correct  this  will 
produce  a  spinal  curve.  The  "head-tilting"  is  due  more  to  an  endeavor  to 
bring  the  predominant  go  degrees  and  i8o  degrees  of  astigmatism  into  a  proper 
line  of  vision  with  the  writing  field,  resulting,  from  the  tilting  of  the  head  and 
body  to  the  left,  in  a  synchronous  rotation  of  the  head  and  body  to  the  right. 
The  preponderance  of  cases  of  lateral  curvature  among  persons  who  habitually 
tilt  the  head  to  one  side  from  astigmatism  is  noticeable,  and  as  an  etiologic 
factor  this  condition  should  receive  careful  consideration.  The  correction  of 
the  astigmatism,  together  with  the  adjustment  of  the  paper  so  that  the  "dom- 
inant" eye  has  a  clear  field  of  vision,  placing  it  preferably  at  an  angle  of  30 
degrees,  and  12  to  14  inches  from  the  eye,  the  head  and  body  being  held  in  the 

*  "Journal  of  the  American  Medical  Association,"  April  22,  1905. 


LATERAL  CURVATURE  OF  THE  SPINE.  575 

normally  erect  position,  will  overcome  the  prevailing  tendency  to  scoliosis  among 
school-children.  The  production  of  torticollis  from  the  effort  to  correct  h)^er- 
phoria  has  been  referred  to  under  that  subject. 

Gould  mentions  the  fact  that  among  the  Orientals  the  custom  of  beginning 
the  writing  at  the  upper  right-hand  corner  of  the  paper,  and  carrying  the  lines 
from  right  to  left,  and  the  habit  of  many  Japanese  and  Chinese  of  holding  the 
paper  in  the  air  in  the  left  hand  at  an  angle  of  from  30  to  50  degrees,  form  a 
notable  contrast  to  the  methods  in  use  among  our  own  and  European  schools. 
This  Oriental  custom  would  give  the  desired  result  of  a  perfectly  erect  and 
hygienic  position  in  writing. 

Malpostures  as  induced  by  deficient  light  in  school-rooms  has  been  inves- 
tigated by  Abbott,*  and  it  was  observed  that  in  the  majority  of  instances  where 
the  light  falling  on  the  desk  was  poor,  the  pupil  would  habitually  assume  a 
faulty  and  deforming  position  in  order  to  secure  as  much  light  as  possible  upon 
the  paper  or  book.  That  the  deficient  light  may  be  considered  as  an  etiologic 
factor  is  emphasized  by  the  fact  that  two  pupUs  in  changing  desks  would  change 
their  postures,  each  one  assuming  the  position  permitting  the  greatest  amount 
of  light  to  reach  his  work. 

Where  a  pupil  was  occasionally  permitted  to  change  his  seat,  the  faulty 
attitude  did  not  become  permanent;  but  where  the  same  position  was  main- 
tained from  day  to  day,  continuously  throughout  the  school  session,  many  of 
the  pupils,  50  per  cent.,  were  found  to  assume  habitual  faulty  attitudes  at  all 
times,  both  in  standing  and  sitting. 

Treatment. 

This  should  be  directed  to  the  removal  of  the  cause,  the  restoration  of  the 
health  and  strength,  and  the  correction  of  the  deformity. 

The  equalization  of  the  extremities,  change  of  occupation,  assumption  of 
a  proper  sitting  position  or  carriage,  and  the  administratiuii  of  remedies  for  the 
correction  of  constitutional  vice,  such  as  preparations  of  cod-liver  oil,  iron,  iodin, 
phosphates,  etc.,  will  all  be  useful  in  accomplishing  a  cure. 

To  correct  or  restore  the  deformity,  properly  directed  gymnastic  exercises 
are  the  most  potent  agents  at  our  command.  To  assure  a  cure,  the  patient 
must  devote  herself  (or  himself)  assiduously  and  persistently  to  the  task  for  a 
long  period.    Self-suspension  with  a  Sayre  apparatus,  double  bar,  horizontal  bar. 


*  "American  Physical  Education  Review,"  March,  1905. 


576 


ORTHOPEDIC  SURGERY. 


trapeze,  or  rings,  should  be  frequently  practised  during  the  day,  alternated  with 
periods  of  recumbency.  In  using  self-suspension  the  rope  should  never  be  tied, 
as  any  accident,  such  as  syncope,  might  result  fatally.  In  all  of  these  exercises, 
where  possible,  the  hand  on  the  concave  side  should  be  uppermost.  While  in 
the  prone  position,  a  hard  curled-hair  pillow,  a  bag  of  sand,  or  an  air-cushion 
should  be  placed  beneath  the  convexity,  or  Wolf's  suspensory  cradle  employed. 
The  treatment  of  the  deformity  in  lateral  curvature  should  be  divided  into 


Fig.  403. — Right  Doksal  Scoliosis  (Hoffa). 


Fig.  404. — Same,  Self-Correction  (Hoffa). 


three  groups  according  to  the  degree.  The  first  group,  or  the  mild  form,  should 
be  treated  by  gymnastic  exercises  with  the  use  of  a  light  support  in  selected  cases. 
The  second,  or  medium  form,  should  be  treated  by  forcible  manual  or  mechanical 
correction  and  the  use  of  suitable  exercises,  corrective  movements,  and  forcible 
manipulations.  The  third,  or  severe  form,  is  not  amenable  to  treatment, 
except  that,  by  means  of  suitable  exercises  and  forcible  correction,  relief  may  be 
obtained  for  the  pressure  pains,  but  the  deformity  will  have  to  be  concealed  as 


LATERAL  CURVATURE  OF  THE  SPINE. 


577 


much  as  possible  by  suitable  clothing,  and  everything  should  be  done  to  make  it 
as  inconspicuous  as  possible. 

The  treatment  which  I  have  found  most  satisfactory  in  the  first  group  of 
cases  consists  in  the  use  of  light  gymnastics,  and  may  be  divided  into  four  parts: 


wlLai    ^B 


Fig.  405. — Habitual  Position.     Scoliosis. 


Fig.  406. — Same,  Good  Correction  by  Suspen- 
SIOI^  (Cohen). 


Fig.   407. — Correction   for  Scoliosis.     Arm   Extension 
WITH  Bells.     Incorrect  Position. 


Fig.  408. — Same,  Correct  Position. 


(i)  the  development  of  the  weak  muscles  by  exercises  adapted  to  them  individu- 
ally or  collectively,  (2)  the  slight  over-development  of  the  weak  muscles,  (3) 
the  development  of  all  the  muscles,  and  (4)  the  use  of  certain  exercises  to  pre- 
vent relapse.     The  exercises  in  each  instance  will  have  to  be  selected  according 

38 


578 


ORTHOPEDIC  SURGERY 


to  the  locality  of  the  curve,  and  as  primary  curves  are  exceedingly  rare,  com- 
binations of  the  exercises  for  the  treatment  of  curves  in  different  parts  of  the 
body  will  have  to  be  employed.  Some  persons  are  not  able  at  first  to  take  such 
exercises  as  are  required  for  the  correction  of  the  particular  curve,  and  in  these 
instances  it  is  necessary  to  begin  with  a  few  general  movements  which  may  be 
taken  in  the  recumbent  position.  The  patient,  lying  upon  the  back,  may  take 
head  rotation,  arm  rotation,  and  leg  rotation,  with  breathing  exercises,  until 


A  B  C 

Fig.  409. — Suspension  Correction  for  Scoliosis. 

A,  Usual  position;    B,  moderate  correction;    C,  best  correction. 


sufificient  control  of  the  muscles  has  been  gained  so  that  the  special  exercises 
may  be  taken  up.  Series  of  exercises  may  be  used  to  treat  the  special  curves, 
the  exercises  which  are  found  most  useful  being  given.  Before  beginning  the 
exercises  the  best  voluntary  position,  known  as  the  best  standing  position,  which 
the  patient  can  assume  should  be  determined,  and  this  should  be  returned  to 
after  each  corrective  exercise  has  been  taken. 

The  first  exercise  will  usually  consist  in  taking  the  position  which  best  cor- 
rects the  deformity,  and  known  as  the  keynote  position.     There  are  many 


LATERAL  CURVATURE  OF  THE  SPINE.  579 

keynote  positions,  the  arms  being  placed  at  different  angles;  for  example,  the 
keynote  position  for  right  dorsal  scoliosis,  the  most  common  form,  is  with  the 
right  arm  extended  sideways,  and  the  left  arm  extended  upward. 

This  keynote  position  places  the  muscles  in  the  best  possible  relation  for 
exercising.  The  use  of  the  spiral  movements,  such  as  the  keynote,  forward 
sideways  turning,  have  been  found  to  be  very  beneficial,  and  the  writer  has  not 
met  any  of  the  bad  effects  from  these  movements  referred  to  by  some 
writers.  The  studies  of  Lovett  would  seem  to  prove  that  the  twisting  and  turn- 
ing movements  of  the  body  might  have  the  effect  of  correcting  rotation  of  the 
bodies  of  the  vertebras.  Special  attention  should  always  be  paid  to  the  devel- 
opment of  the  lower  extremities,  both  because  these  are  frequently  unequally 
developed,  and  because  it  is  necessary  to  have  a  firm  base  of  support  upon  which 
to  erect  a  straight  superstructure. 

In  taking  all  these  movements  for  the  correction  of  the  curvature,  the 
greatest  care  should  be  exercised,  and  the  patient  should  be  constantly  under 
the  observation  of  the  surgeon.  The  tendency  of  surgeons  to  relegate  the  treat- 
ment of  lateral  curvature  to  trained  assistants  is  to  be  condemned,  and  the 
preference  should  be  given  to  treatment  by  trained  assistants  under  the  daily 
supervision  of  the  surgeon. 

The  treatment  should  be  given  daily  for  periods  of  from  three  to  six  months, 
preferably  the  latter,  and  the  tendency  to  insert  new  exercises  from  time  to 
time  in  order  to  please  the  individuals  is  not  to  be  recommended.  A  certain 
amount  of  variety  may  be  permitted,  but  it  is  better  occasionally  to  change  the 
exercises,  returning  frequently  to  those  which  are  found  to  be  the  most  beneficial, 
or,  better  still,  to  continue  those  which  are  the  most  useful,  supplementing 
these  from  time  to  time  with  others. 

The  use  of  massage  after  the  exercises  have  been  taken  is  a  subject  which  is 
deserving  of  some  consideration.  The  writer  is  of  the  opinion  that  patients  do 
better  who  have  daUy  massage  after  their  exercises  than  those  who  do  not. 
The  massage  should  consist  of  several  different  movements  intended  to  improve 
the  weaker  muscles,  to  divert  the  blood  from  the  spinal  column,  and  to  rest  the 
patient  after  the  exercises. 

The  exercises  should  be  taken  daily  except  Sundays.  During  the  men- 
strual period  the  exercises  should  be  omitted  entirely  for  a  day  or  two,  and  the 
hip  and  hanging  movements  should  be  discontinued  until  the  cessation  of  the 
flow.     During  the  summer  the  exercises  may  be  modified,  and  in  many  instances 


580 


ORTHOPEDIC  SURGERY. 


it  is  best  to  discontinue  them  altogether,  depending  upon  the  outdoor  life  of  the 
individuals  for  the  necessary  exercise. 

Patients  who  are  being  treated  for  lateral  curvature  should  not  be  permitted 
to  attend  school,  since  school  life  not  only  fatigues  but  interferes  with  the  proper 
amount  of  rest  required  by  the  individual.  Patients  should  not  be  permitted  to 
go  out  in  society,  nor  be  encumbered  with  social  engagements  of  any  kind.  The 
morning  of  each  day  should  be  devoted  to  the  treatment,  and  at  least  two  hours 
in  the  afternoon  should  be  spent  in  the  prone  position.     Late  hours  should  be 

avoided,  and  evening  entertainments 
should  be  interdicted.  All  games  which 
employ  one  side  of  the  body  more  than  the 
other  should  be  forbidden.  And  the  possi- 
bility of  the  one-sided  games  producing 
lateral  curvature  should  not  be  forgotten. 
The  writer  has  met  individuals  otherwise 
very  well  developed  who  were  deformed 
from  playing  ball  to  an  unusual  degree. 

The  breathing  should  be  carefully 
regulated  during  the  taking  of  the  exer- 
cises, and  at  the  end  of  each  movement 
one  or  two  full  inspirations  should  be 
slowly  taken. 

Particular   attention   should  be   paid 
to  the  muscles  upon  the  convexity  of  the 
curve,  as  these  are  the  weaker  muscles. 
In  carrying  out  the  treatment  the  skeleton 
is  placed  in  such  a  position  that  the  mus- 
cular attachments  assume  a  more  normal 
position  and  can  therefore  be  developed 
through  their  proper  contraction  and  relaxation.     No  series  of  exercises  can  be 
followed  arbitrarily,  but  the  special  exercises  required  in  each  individual  case 
should  be  prescribed  by  the  surgeon. 

The  special  exercises  used  in  right  dorsal  scoliosis  are  as  follows: 
I.  Best  standing  position. — This  corresponds  to  the  standing  fundamental 
position  described  in  all  standard  works  upon  Swedish  gymnastics. 

•  2.  Kej-note  position. — In  this  position  the  arms  are  slowly  raised  shoulder 
high  and  the  left  arm  is  gradually  carried  straight  upward  in  extreme  extension 


Fig.  410. — Best  Standixg  Position 


Fig.  411. — Keynote  Position.  Fig-  412.— Keynote— Sideways  Bending  to  Right. 


Pig.  413. — Keynote — Fouw.\rd  Sidew.\vs  Turning. 


LATERAL  CURVATURE  OF  THE  SPINE. 


583 


with  the  hands  in  the  frontal  plane  and  the  palms  turned  directly  forward.  The 
arm  is  then  slowly  lowered  until  it  is  shoulder  high,  and  both  arms  are  then  low- 
ered until  the  fundamental  standing  position  is  reached. 

3.  Keynote,  forward  bending. — The  patient  assumes  the  keynote  position, 
the  body  is  carried  slowly  forward  by  flexion  in  the  hip-joints  until  the  stoop 
standing  position  is  reached.  The  knee-joints  are  in  full  extension,  the  head 
bent  slightly  backward,  and  the  gaze  directed  forward.  From  this  position  the 
patient  returns  gradually  to  the  ke5mote  and  fundamental  standing  positions. 


Fig.  414. — Keynote — Knee-bending,  Toe-standing. 


Fig.  415. — Keynote — Fall  Out,  St-^nding. 


4.  Keynote,  sideways  bending,  to  right. — The  keynote  position  is  assumed 
and  the  patient  slowly  bends  the  whole  spine  to  the  right,  keeping  the  shoulders 
and  hips  in  the  sagittal  plane,  until  the  body  assumes  the  side-bend-standing 
position.  The  patient  then  gradually  returns  to  the  keynote  and  fundamental 
standing  positions. 

5.  Keynote,  forward  sideways  turning. — The  keynote  position  is  assumed, 
and  the  patient  combines  the  twist-standing  with  the  stoop-standing  positions 
until  an  extreme  combination  of  these  two  positions  is  reached,  care  being  taken 


584 


ORTHOPEDIC  SURGERY 


not  to  alter  the  position  of  the  feet.     The  patient  then  returns  to  the  ke}Tiote 
and  fundamental  standing  positions. 

6.  Keynote,  heels  rising. — The  patient  assumes  the  keynote  position,  and 
then  gradually  raises  the  body  until  the  weight  rests  entirely  upon  the  balls  of 
the  toes,  and  from  this  position  returns  slowly  to  the  keynote  and  fundamental 
standing  positions. 

7.  Keynote,  knee-bending,  toe-standing. — The  patient  assumes  the  key- 
note position  and  gradually  raises  the  body  from  this  position  by  raising  the 


Fig.    416.- 


-Hanging — Right    Leg   Raise   with 
Resistance. 


-Hanging — Knees    Abducting    with 
Resistance. 


heels,  combined  with  bending  the  knees,  and  then  gradually  returns  to  the  keynote 
and  fundamental  standing  positions. 

8.  Keynote,  fall  out  standing. — The  patient  assumes  the  keynote  position 
and  then  moves  the  right  leg  forward  at  an  angle  of  60  degrees  three  foot  lengths, 
at  the  same  time  bendmg  the  right  knee  and  keeping  the  other  knee  in  full 
extension,  while  the  trunk  is  carried  over  the  bent  knee.  This  position  is  main- 
tained for  ten  seconds,  after  which  the  patient  gradually  returns  to  the  keynote 
and  fundamental  standing  positions. 


LATERAL  CURVATURE  OF  THE  SPINE.  585 

9.  Hanging,  right  leg  raise  with  resistance. — The  patient  standing  beneath 
the  boom,  which  is  inclined  with  the  left  end  four  inches  higher  than  the  right, 
or  else  beneath  rings,  the  left  one  of  which  is  three  inches  higher  than  the  right, 
takes  hold  of  the  boom  or  rings  with  the  hands  separated  the  width  of  the 
shoulders,  and  suspends  the  body  in  such  a  manner  that  the  feet  swing  clear 
of  the  floor.  The  right  knee  is  slowly  flexed  forward,  resistance  being  made 
by  the  attendant. 

ID.  Hanging,  knees  abduct  with  resistance. — The  patient  takes  the  same 
hanging  position  as  in  No.  9  and  abducts  the  knees,  the  attendant  resisting. 

II.  Hanging,  knees  adduct  with  resistance. — The  patient  assumes  the  same 


Fig.  418. — Prone.     Keynote — Backward  Sideways  Turn. 

hanging  position  as  in  No.  9  and  slowly  adducts  the  knees,  the  attendant  re- 
sisting. 

12.  Supine,  right  hip  flex  with  resistance. — The  patient  assumes  the  lying 
fundamental  position  and  flexes  the  right  knee  and  hip,  the  attendant  resisting. 

13.  Supine,  right  hip  extend  with  resistance. — The  patient,  in  the  lying 
fundamental  position,  flexes  the  right  knee  and  hip,  after  which  the  knee  and 
hip  are  extended,  the  attendant  resisting. 

14.  Supine,  right  hip  rotate  with  resistance. — The  patient  assumes  the 
lying  fundamental  position  and  the  attendant  rotates  the  hip  with  resis- 
tance. 

15.  Prone,  keynote,  backward  sideways  turn. — The  patient  lies  upon  the 
table,  face  downward,  and  slowly  raises  the  arms  to  the  keynote  position.  The 
limbs  are  firmly  held  by  the  attendant  or  are  strapped  into  position,  and  the 


586 


ORTHOPEDIC  SURGERY. 


patient  bends  the  body  backward  and  to  the  right.  The  efficiency  of  this  move- 
ment may  be  increased  by  the  patient  assuming  the  stretch  forward  lying  posi- 
tion, the  Hmbs  being  strapped  into  place,  and  the  attendant  supporting  the 
patient's  arms. 

i6.  The  patient  assumes  the  same  position  as  in  No.  15,  and  swimming 
movements  may  be  taken.  Or  this  position  may  be  assumed,  the  body  of  the 
patient  extending  over  the  end  of^the  table,  in  the  leg  forward  lying  position,  the 
movements  may  be  taken,  with  resistance  by  the  attendant. 


Fic.  419. — Salute. 


Fig.  420. — Hips  Firm,  Ride  Sitting,  Trunk  Alter- 
nate Twisting. 


17.  Salute. — The  patient  assumes  the  fundamental  standing  position, 
flexes  the  right  forearm,  carries  the  arm  upward  shoulder  high,  and  slowly 
stretches  it  outward  on  a  level  with  the  horizontal  plane  of  the  shoulders,  keep- 
ing the  hand  with  the  palm  turned  downward,  after  which  the  fundamental 
standing  position  is  again  gradually  assumed. 

18.  Hips  firm,  ride  sitting,  trunk  alternate  twisting. — The  patient  sits 
astride  on  the  plinth  with  the  pelvis  and  legs  fixed,  the  attendant  standing  behind 
the  patient  and  placing  her  left  hand  beneath  the  left  shoulder  slowly  lifts  it, 


LATERAL  CURVATURE  OF  THE  SPINE. 


587 


at  the  same  time  depressing  the  right  scapula  with  her  right  hand,  after  which 
the  left  shoulder  and  right  scapula  are  allowed  to  return  slowly  to  the  original 
position.  Exercises  Nos.  3,  4,  and  5  can  be  given  with  great  advantage  on  the 
plinth,  as  may  also  the  swimming  movements. 

Exercises  Nos.  3,  4,  and  5  may  also  be  given  with  advantage  in  the  leg  lean 
standing  position;  that  is,  with  the  patient  resting  the  front  part  of  the  thighs 
against  the  boom. 

It  will  be  noted  that  in  these  exercises  for  risrht  dorsal  scoliosis  there  are 


Fig.  421. — Exercise  on  Plinth.     Keynote  Position. 


Fig.  422. — Exercise   on  Plinth.     Arms  Extend,  For- 
w.^RD  Bend. 


certain  movements  given  for  the  correction  of  left  lumbar  scoliosis  which  is  some- 
times secondary  to  the  right  dorsal  scoliosis. 

The  photographs  illustrating  the'special  exercises  for  the  first  group  of  cases 
are  taken  from  a  model.  Patients  when  taking  these  exercises  wear  a  special 
gown  which  exposes  only  the  back. 

The  inequality  of  the  lower  extremities  must  be  corrected.  For  example, 
the  right  or  long  limb  in  right  dorsal  scoliosis  must  be  contracted  by  the  fall-out 
standing  position,  No.  8,  and  by  the  other  special  exercises,  Nos.  9  to  14,  inclu- 


5SS 


ORTHOPEDIC  SURGERY 


sive,  which  tend  to  shorten  the  muscles  about  the  hip-joint.     Traction  can 
also  be  made  upon  the  short  limb. 


Fig.  423. — SwiMMNG  Movements  (Berger  and  Banzet). 


Fig.  424. — Corrected  Position.    Trunk  Raised  in  Ventral  Decubitus  (Berger  and  Banzet). 


Fig.  425. — Lateral  Correction.     Trunk  in  Prone  Lateral  Extended  Position  (Berger  and  BanzeO. 


The  exercises  for  left  dorsal  scoliosis  are  the  same  as  those  for  the  right  dorsal, 
with  the  positions  of  left  and  right  exactly  reversed. 


LATERAL  CURVATURE  OF  THE  SPINE. 


589 


Each  of  the  foregoing  exercises  should  be  taken  once  a  day,  beginning 
with  ten  times  each,  and  gradually  increasing  the  number  until  twenty-five 
is  reached,  and  in  certain  special  exercises  the  number  may  be  increased  to 
fifty  times. 

Exercises  on  the  plinth  wUl  be  found  of  great  value.  The  same  exercises 
which  have  already  been  given  to  be  taken  in  the  standing  position, — keynote 


Fig.   426.— Severe  Scoliosis.     Before   Treatment 
(Hovorka). 


Fig.  427. — Same,  .^fter  Tre.^tment  (Hovorka). 


forward  bending,  keynote  sideways  bending  to  the  right,  and  keynote  forward 
sideways  turning,  and  also  the  swimming  movements  may  be  taken  while  sit- 
ting with  the  limbs  strapped  to  the  plinth;  the  advantage  of  exercises  taken  in 
this  position  is  that  the  pelvis  is  fixed. 

Other  exercises  may  be  taken  in  the  prone  position  upon  a  table  or  couch. 
Lying  upon  the  face,  swimming  movements  may  be  taken.  Lying  upon  the 
face  with  the  feet  fixed,  the  trunk  may  be  raised  to  the  corrected  position;  and 


590 


ORTHOPEDIC  SURGERY. 


lying  upon  the  face  with  the  feet  fixed  and  the  right  hand  resting  upon  the 
prominent  ribs,  the  trunk  may  be  raised  to  a  lateral  position. 

Where  the  lumbar  scoliosis  is  primary,  additional  exercises  are  given  for 
the  correction  of  this  curve.  These  should  consist  principally  of  the  hanging 
movements  with  flexion,  extension,  and  circumduction  of  the  hip.  In  the  left 
lumbar  scoliosis  which  occurs  as  a  secondary  condition  to  right  dorsal  scoliosis 
the  right  hip  should  be  flexed,  rotated,  and  circumducted.     The  entire  right 

limb  is  held  firm  by  fijcation  of  the  knee- 
joint  and  ankle-joint,  and  is  raised  by  the 
patient,  the  attendant  resisting  downward 
by  holding  the  foot. 

In  the  treatment  of  primary  cervical 
curves  special  exercises  should  be  given 
to  develop  the  convex  side  of  the  curve. 
The  patient  being  in  the  ride  sitting  posi- 
tion on  the  plinth,  the  head  is  carried 
toward  the  convex  side  with  resistance. 

The  patient,  in  the  supine  position, 
should  also  take  head  movements  consist- 
ing of  flexion,  extension,  and  circumduc- 
tion, with  the  head  and  neck  extending 
over  the  end  of  the  table  and  the  arms 
placed  alongside  of  the  body  with  the 
palms  turned  upward,  resistance  being 
made  by  the  attendant. 

After  the  deformity  has  been  cor- 
rected by  these  various  exercises  they 
should  be  continued  until  slight  over- 
development of  the  weak  muscles  has 
been  attained,  after  which  the  keynote  position  shoifld  be  abandoned,  and 
exercises  substituted  with  both  arms  extended  shoulder  high,  with  both  arms 
elevated,  or  with  the  arms  in  the  neck  rest  position.  With  these  positions 
as  fundamental,  standing  position  exercises  Nos.  3,  4,  5,  6,  7,  and  8  should 
be  given  and  the  other  exercises  given  as  before.  In  this  manner  the  general 
muscular  development  will  be  accomplished,  and  after  the  patient  has  been 
dismissed  this  general  development  may  be  continued  by  the  use  of  certain 
exercises  as  published  by  Dr.  Keating  and  myself,*  as  follows: 

*  Keating's  "Cyclopedia  of  the  Diseases  of  Children,"  vol.  iv. 


Fig.  428. — Shai-fer  Spine  Brace  Applied 
TO  Case  of  Left  Dorsal  Scoliosis. 


LATERAL  CURVATURE  OF  THE  SPINE. 


591 


"i.  Neck  rest  standing,  heel  rising. 

"2.  Neck  rest  standing,  trunk  change  turning. 

"3.  Stretch  standing,  trunk  sideways  bending. 

"4.  Stretch  stride  standing,  trunk  forward  bending. 

"5.  Half  stretch  walk,  standing  position. 

"6.  Stretch  walk  standing,  trunk  turning  position. 

"7.  Yard  walk,  fall  standing  position. 

"8.  Stretch  standing,  heels  rising,  knee  bending." 

The  use  of  bilateral  exercises  has  been  recommended  by  some  surgeons. 
When  these  are  employed,  they  do  not  differ  materially  from  the  gymnastic 
exercises  for  general  developmental  work,   except  that   greater  attention    is 
paid  to  the  correctness  of  posture  and  the  precision  with 
which  the  work  is  done. 

There  has  also  been  a  tendency  to  introduce  the  use 
of  heavy  gymnastics.  As  employed  by  Teschner,  these 
represent  muscular  development  as  taught  by  Attilla,  the 
trainer  of  Sandow.  This  method  consists  essentially  in 
the  systematic  cultivation  of  all  the  muscles  of  the  body  in 
addition  to  those  which  are  particularly  affected.  It  in- 
sists upon  the  muscular  effort  being  carried  to  the  point 
of  fatigue,  the  work  being  increased  from  day  to  day,  and 
the  course  being  a  rapid  one.  It  includes  systematic  ex- 
ercises with  light  dumb-bells  followed  by  the  use  of  heavy 
weights,  principally  steel  bars  and  bar  bells  weighing  from 
26  to  72  pounds.  The  effort  required  to  lift  the  heavy 
weights  has  a  tendency  to  straighten  the  spine,  and  the 

method  has  been  used  with  advantage  in  cases  of  general  lack  of  development 
of  the  muscles  of  the  back.  This  method  requires  the  same  personal  attention 
and  the  same  precision  in  its  use  as  in  the  employment  of  the  light  gymnastics 
already  mentioned.  It  has  been  fully  described  and  illustrated  in  the  "Annals 
of  Surgery"  for  August,  1895. 

On  account  of  the  danger  of  overwork  this  system  should  only  be  employed 
under  the  personal  direction  of  a  physician. 

After  the  first  few  lessons,  the  exercises  become  a  pleasant  pastime,  and  the 
rapid  and  constant  improvement  leads  the  ambitious  on  to  the  acquisition  of  a 
perfect  figure,  with  a  buoyancy  and  vigor  of  health  before  unknown.  In  the  first 
group  of  cases  braces  are  not  necessary  and  should  not  be  recommended,  since 


Fig.  429. — Lateral   Cur- 
vATtTRE  Brace. 


592 


ORTHOPEDIC  SURGERY 


the  greatest  dependence  must  be  placed  in  properly  selected  exercises  for  the 
accomplishment  of  the  cure. 

Treatment  of  the  Second  Group  of  Cases. — In  the  treatment  of  the  sec- 
ond group  of  cases  of  scoliosis  the  exercises  already  described  will  be  of  some 
service  to  render  the  curves  more  flexible,  but  resort  must  be  had  to  the  use  of 

'  corrective  apparatus  of  all  kinds,  manipu- 

lations, both  manual  and  instrumental, 
and  the  use  of  orthopedic  appliances.  The 
gymnastic  apparatus  which  will  be  found 
valuable  include  Swedish  rods,  boom,  stall 
bars,  high  plinth  and  low  plinth. 


Fig.  430. — Beely  Corrfctino  Machine  for  Lateral 
Curvature. 


Fig.  431. — Beely-R.4dibo\  Correcting  Machine. 


Of  the  mechanical  supports,  I  have  found  a  modified  Shaffer  brace  when 
well  fitted  to  be  a  valuable  accessory  to  treatment.  (Fig.  428.)  This  consists 
of  a  well-fitted  steel  waist-band,  with  diverging  steel  pieces  in  front  and  back 
attached  together  with  webbing;  from  this  waist-band  is  built  up  a  crutch 
under  the  depressed  shoulder,  and  a  pad  over  the  deformity.     Strong  webbing 


LATERAL  CURVATURE  OF  THE  SPINE. 


593 


straps  pass  between  the  pad  and  the  crutch  in  front  and  behind,  and  act  later- 
ally upon  the  prominence.  The  modifications  made  by  the  writer  are  a  flattened 
axiUary  crutch  after  the  pattern  of  Ernst,  of  London,  and  an  increased  number 
of  straps  of  webbing  below  the  band  to  insure  greater  stability.  An  apparatus 
of  this  character  may  be  incorporated  into  a  jean  corset,  or  in  some  instances 
a  neat  fitting  corset  may  be  reinforced  with  light  steels,  with  a  padded  crutch 
under  the  axilla  of  the  low  shoulder.  It  is,  however,  to  be  clearly  understood 
that  these  appliances  do  not  aim  to  correct  the  deformity  by  direct  pressure, 
but  are  employed  rather  as  a  reminder  to  the  patient  to  assume  a  correct  posi- 


FiG.  432. — Lateral  Susi'ensiun  Apl'aratus  of  Redaed.     Sele- 

CORRECTION. 


Fig.   433. — Lateral  Suspension  Apparatus  of  Redard. 
Manual  Correction. 


tion,  and  as  a  slight  support  to  the  body  during  the  intervals  of  exercise  and 
recumbency.  Where  a  brace  is  desired  to  correct  the  deformity  by  continuous 
pressure  upon  the  convex  side,  a  heavier  appliance  with  two  steel  pelvic  bands, 
uprights,  crutches,  etc.,  will  be  required.  Of  such  a  pattern  are  the  Redard, 
Gefnert,  and  all  braces  constructed  upon  the  original  Sheldrake  model. 

Mechanical  Correction. — The  corrective  apparatus  are  for  the  most  part 
constructed  upon  one  of  two  principles,  either  gymnastic  apparatus  used  as 
corrective  machines  or  machines  for  the  mechanical  stretching  of  the  contracted 
curves. 

39 


594 


ORTHOPEDIC  SURGERY. 


The  first  are  represented  by  the  movable  inclined  planes  by  which  the 
patient  is  suspended  and  uses  the  body-weight  to  assist  the  correction,  as  in  the 
Redard  apparatus,  where  the  patient  lies  upon  a  plane  and  the  feet  are  grad- 
ually lowered  to  make  the  corrective  pressure. 


Fig.  434. — Beelv's  Correcting  Machine  for  Scoliosis. 


The  same  principle  is  used  in  the  Lorenz  swing,  where  the  patient  hangs 
upon  a  frame  and  is  gradually  lifted  oft"  his  feet  by  the  movement  of  the  frame. 
There  are  many  others  constructed  upon  the  same  pattern,  and  all  are  an 
exaggerated  reproduction  of  the  Shaw  couch,  so  much  employed  sixty  years 


LATERAL  CURVATURE  OF  THE  SPINE. 


595 


Correcting  Machines. — The  mechanical  correction  of  scohosis  has  become 
popular  only  within  the  past  decade.  The  principle  of  all  is  the  same,  and 
experience  has  shown  how  much  force  can  be  applied  with  advantage,  and 
without  injury. 

Two  forms  of  appliances  are  employed: 

I.  Those  which  place  the  trunk  in  corrective  attitudes,  and  apply  pressure 


Fig.  435. — Same  Applied. 


by  means  of  bands  or  straps,  with  or  without  self-suspension.  The  best 
example  of  this  form  is  that  of  Beely — a  square  framework  in  which  the  patient 
is  placed  and  in  which  weights  and  straps  act  as  correcting  agents.  This  has 
been  improved  by  Radike. 

2.  Those  in  which  the  principle  of  self-suspension  is  combined  with  pres- 
sure.    The  original  example  of  Schede  has  been  much  improved  by  Hoffa, 


596 


ORTHOPEDIC  SURGERY. 


has  been  modified  by  Bradford  and  Brackett,  and  has  reached  its  highest  per- 
fection in  the  Weigel  machine. 

These  machines  are  of  the  greatest  value  in  the  correction  of  the  rotation 
which  complicates  the  severe  t3^es.  The  patient  remains  in  the  machine  for 
from  ten  to  thirty  minutes  for  one  or  two  periods  each  day,  wearing  a  correcting 


Fig.  436. — Manual  Correction  of  Scoliosis  (Redard). 


Fig.  437. — Levee  Correction  of  Scoliosis  (Redard). 


brace  or  modeled  plaster  cast  during  the  interval,  and  retaining  the  horizontal 
position  for  several  hours  daily. 

When  it  is  desired  to  maintain  the  correction,  a  plaster-of-Paris  cast  may 
be  put  on  while  the  patient  is  in  the  machine.  A  better  method  is  that  of 
Redard.  The  patient  is  corrected  in  the  horizontal  position,  and  the  pressure 
pad  used  for  the  correction  is  incorporated  in  the  dressing. 

Lovett  employs  an  apparatus  constructed  by  Adams  which  provides  for  the 


LATERAL  CURVATURE  OF  THE  SPINE. 


597 


independent  or  combined  correction  of  both  lateral  curvature  and  rotation  of 
the  spine.     Its  description  may  best  be  talvcn  from  Lovett's  article*: 

"The  apparatus  consists  of  a  heavy  gas-pipe  frame  three  by  four  feet. 
The  patient  Hes  face  downvi^ard  on  two  webbing  strips  running  from  end  to  end 
of  the  frame  with  the  legs  flexed.     Near  the  bottom  of  the  frame  is  an  adjust- 


-Frame  for  Forcible  Instrumental  Correction  of  Scoliosis  (Redard). 


Fig.  439. — Same,  showing  Plasters  Applied  (Redard). 

able  crossbar  bent  to  fit  into  the  flexure  between  the  thigh  and  the  pelvis  on  which 
the  patient  rests  the  lower  part  of  the  body.  Sliding  on  this  bar  are  two  arms 
which  slide  in  and  clamp  down  on  the  buttocks,  holding  the  pelvis  steady  on 
the  crossbar.     This  bar  is  movable  from  side  to  side  in  order  to  induce  or  cor- 


*  "Boston  Medical  and  Surgical  Journal,"  March  17,  1904. 


598 


ORTHOPEDIC  SURGERY. 


rect  curvature  in  the  lumbar  region  when  necessary.  There  are  three  vertical 
transverse  rings  tv^^o  feet  in  diameter  fastened  to  pieces  on  the  sides  of  the  frame 
so  that  they  can  be  moved  to  any  desired  point  along  the  frame.  These  rings 
are  also  movable  from  side  to  side,  and  by  an  independent  movement  they  can 


Fig.    440. — P.\TIENT    BEFORE     FORCIBLE    CORREC- 
TION (Redard"). 


Fig.   441. — Same,   .u-tee   Forcible   Correction 
(Redard). 


also  be  rotated  through  a  half  circle.  Any  one  of  these  movements  can  be 
checked  at  any  point  by  turning  a  screw.  The  shoulders  are  held  by  a  pair  of 
axillary  straps  fastened  together  by  a  strap  across  the  chest  in  front.  These 
straps  are  suspended  from  the  ring  nearest  to  the  top  of  the  frame  and  can  be 


-« 

^ 

A 

> 
1 

IP 

@P 

^^**^aB' 

"^Hm 

Hbm 

/             ^ 

^  '^ 

^^m  w-rM 

Fig.  442. — LovETT  Corrective  Apparatus 


Fig.  443. — LovETT  Corrective  Apparatus.    Patient  in  Position. 


LATERAL  CURVATURE  OF  THE  SPINE.  601 

made  to  hold  the  shoulders  in  any  desired  degree  or  twist  by  a  rotation  of 
the  ring. 

"Each  ring  is  provided  with  two  long  screws  at  the  two  poles  of  the  ring. 
These  screws  are  adjustable  upon  the  ring  and  can  be  set  at  any  desired  angle 
to  it.  By  rotating  the  ring  and  adjusting  the  angle  of  the  screws  they  can  be 
made  to  screw  down  or  up  upon  any  part  of  the  back  or  chest." 

The  patient  is  placed  face  downward  on  the  two  webbing  strips  with  the 
buttocks  fixed  by  the  adjustable  crossbar,  the  feet  resting  upon  the  floor,  and  the 
arms  extended  above  the  head.  The  shoulders  are  held  by  bandages  attached 
to  the  upper  ring  and  passing  across  the  axilla,  together  with  screw  pressure  up 
or  down  if  necessary.  The  rings  are  then  moved  opposite  to  those  places  where 
it  is  desired  to  make  correction. 

Correction  of  lateral  curvature  is  made  by  passing  a  broad  bandage  over  a 
protective  pad  of  felt  on  the  patient's  side,  the  cords  of  the  bandage  being  fastened 
to  the  ring  on  the  other  side.  Then  by  moving  the  entire  ring  laterally  the 
bandage  is  tightened  and  any  desired  amount  of  corrective  force  may  thus  be 
applied.  Correction  of  rotation  is  next  made  by  rotating  the  rmg  until  the 
screws  are  opposite  the  desired  point,  when  they  are  screwed  down  upon  the 
patient.  The  points  of  the  screws  are  protected  by  pads  of  sheet-iron,  two  by 
three  inches,  faced  with  heavy  felt  to  prevent  injury  to  the  patient. 

A  plaster-of-Paris  cast  or  other  retentive  jacket  is  then  applied  in  the  cor- 
rected position  and  worn  for  a  suitable  length  of  time.  Such  a  jacket  would 
necessarily  have  to  have  the  pads  incorporated  in  it,  as  the  corrective  force  is 
not  removed  until  the  retentive  dressing  is  properly  adjusted. 

Third  Group. — Much  has  been  written  of  late  about  fixed  and  flexible 
curves,  the  former  being  included  under  the  present  group  of  cases,  in  which 
the  curve  is  not  at  all  influenced  by  self-suspension.  The  treatment  should 
consist  in  a  persistent  effort  to  render  the  curves  flexible  by  means  of  manipula- 
tions, exercises,  and  machines.  If  the  curve  is  made  more  flexible,  then  these 
cases  should  be  treated  in  the  same  manner  as  the  second  group,  which  has 
already  been  described.  In  all  persons  suffering  from  this  degree  of  deformity 
pain  is  very  constant  and  distressing,  and  this  should  be  relieved  by  extension, 
self-suspension  from  a  bar,  the  use  of  extension  machines,  breathing  exercises, 
and  the  use  of  all  means  which  will  expand  the  chest  and  relieve  the  pressure 
of  the  ribs.  The  local  application  of  anesthetics  will  be  found  beneficial,  such 
as  baum  analgesique,  mesotan  ointment,  25  per  cent.,  with  petrolatum,  or  ofl  of 
betulol,  etc.     When  the  condition  is  extreme,  relief  may  sometimes  be  obtained 


602  ORTHOPEDIC  SURGERY. 

for  the  excruciating  pain  by  the  excision  of  a  rib,  the  writer  having  practised 
this  with  great  satisfaction  in  selected  cases. 

Tenotomy,  myotomy,  and  forcible  restoration  have  been  advocated  from 
time  to  time,  but  have  fallen  into  disuse.  Operative  interference  undertaken 
with  the  object  of  removing  the  prominence  by  resection  of  ribs  was  suggested 
by  Volkmann  in  1889,  and  was  twice  performed  by  Hoffa  in  1896.*  An  opera- 
tion advocated  by  Shaffer  f  for  the  correction  of  rotating  scoliosis  has  been  per- 
formed upon  the  cadaver.  More  recently  Hokef  has  performed  a  carefully 
planned  and  successful  operation  consisting  of  the  section  of  a  number  of  ribs 
upon  the  prominence  of  the  deformity.  This  operation  was  performed  as  a 
preliminary  to  correction  by  plaster-of-Paris  jackets. 

For  the  complete  literature  of  lateral  curvature  see  Arnd,  "Archiv.  Ortho- 
paed.,  Mechan.,  u.  Undfall,"  Bd.  i,  Heft  ii,  1904. 

*  "  Zeit.  f.  orth.  Chir.,"  1896,  p.  401. 

t  "Am.  Med.  and  Surg.  Bulletin,"  Jan.  i,  1894;   Feb.  15,  1894. 

J  "  Amer.  Jour.  Orth.  Surg.,"  vol.  i,  No.  2. 


CHAPTER  XVIII. 
INFANTILE  SPINAL  PARALYSIS. 

Infantile  paralysis  is  an  acute,  more  rarely  a  chronic,  inflammatory  affec- 
tion of  the  large  multipolar  ganglion  cells  in  the  anterior  cornua  of  the  cord, 
characterized  by  a  sudden  loss  of  power  of  the  voluntary  muscles  unaccom- 
panied by  any  sensory  changes,  and  resulting  in  atrophy  in  one  or  more  muscles 
or  groups  of  muscles  with  deformity. 

Synonyms.— English,  Infantile  Paralysis;  Infantile  Spinal  Paralysis; 
Essential  Paralysis;  Atrophic  Paralysis;  Paralysis  during  Dentition ;  Regressive 
Paralysis;  Myelitis  of  the  Anterior  Horns;  Tephromyelitis ;  Myogenic  Par- 
alysis; Poliomyelitis  Anterior,  i^rewc/j,  Paralysie  Infantile;  Paralysie  Spinale; 
Paralysie  Atrophique  Graisseuse  de  I'Enfance;  Paralysie  Essentielle;  Teph- 
romyelite  Anterieure  Aigue.  German,  Kinderlahmung;  Spinale  Kinderlah- 
mung.  Italian,  Poliomieliti;  Paralisi  atrofica  dei  bambrici;  Mieliti  anteriora. 
Spanish,  Paralisis  atrofica  infantil. 

Etiology. 

Anterior  poliomyelitis  is  usually  considered  to  be  pecuHarly  an  affection 
of  childhood  and  infancy,  and  hence  is  generally  termed  infantile  spinal  palsy — 
the  name  given  it  in  1840  by  Heine.  It  was  not  until  1873  that  the  first  adult 
case  was  described  by  Gombault,  and  three  more  by  Bernhardt  in  1874,  two 
of  which  cases  had  paralysis  of  all  four  extremities.  The  mortality  and  severity 
of  the  disease  would  seem  to  be  higher  in  adult  cases.  The  differential  diag- 
nosis between  Landry's  paralysis  and  anterior  poliomyelitis,  and  the  neuroses  and 
anterior  poliomyelitis,  would  seem  to  be  so  difficult  in  the  adult  that  in  many 
cases  the  diagnosis  cannot  be  made  without  pathologic  corroboration.  It  is 
stated  by  Taylor  that  many  so-called  cases  of  Landry's  palsy  have  been  subse- 
quently proved  by  postmortem  findings  to  be  anterior  poliomyelitis.  During  his 
four  years  and  three  months'  service  at  the  Out-patient  Department  of  the 
Massachusetts  General  Hospital  76  cases  were  diagnosed  as  adult  anterior 
poliomyelitis,  10  of  which  were  upward  of  twelve  years  and  five  of  which  were 
eighteen  years  and  more.     The  relative  frequency  of  the  affection  in  childhood 


604  ORTHOPEDIC  SURGERY. 

may  be  inferred  from  the  statement  of  Holmes  Coote,  that  out  of  looo  children 
in  the  Royal  Orthopedic  Hospital,  80,  or  8  per  cent.,  suffered  from  infantile 
palsy.  It  is  said  to  be  the  most  frequent  spinal  cord  disease  in  children,  an 
acute  transverse  myelitis  rarely  occurring  before  the  tenth  year,  and  then  not 
so  frequently  as  anterior  poliomyelitis,  and  a  disseminated  or  focal  myelitis 
occurring  sometimes  in  zymotic  disease  among  children.  As  to  the  possibility 
of  the  intrauterine  development  of  the  paralysis,  the  vi^riter  believes,  with  Gowers, 
that  there  is  as  yet  no  valid  evidence,  and  certain  it  is  that  most  of  the  cases  of 
congenital  club-foot  (equino-varus)  are  not,  as  some  vi^riters  believe,  the  result 
of  an  intrauterine  palsy.  It  may  come  on  soon  after  birth,  as  in  the  case  of 
Duchenne,  which  was  attacked  on  the  twelfth  day,  and  that  of  Bramwell,  which 
developed  when  the  child  was  three  weeks  old,  and  also  that  of  Schultze,  which 
occurred  in  a  baby  of  four  weeks;  but  it  is  infrequent  during  the  first  year, 
being  rare  in  the  first  six  months.  The  great  majority  of  cases  occur  between 
the  ages  of  six  months  and  three  years;  this  being  the  period  of  primary  denti- 
tion. There  is,  however,  no  proof  of  the  relationship  between  dentition  and 
the  disease.  Other  factors  in  this  relative  frequency  may  be  found  in  the  fact 
that  this  period  is  also  that  during  which  children  learn  to  walk,  and  hence, 
according  to  the  theory  of  Ashby  and  Wright,  overexert  the  leg  muscles,  pro- 
ducing a  peripheral  irritation,  and  also  because  during  this  time  they  are  espe- 
cially prone  to  exhausting  digestive  disturbances.  It  is  probable,  as  remarked 
by  Meigs  and  Pepper,  that  early  age  and  dentition  only  act  indirectly  by 
inducing  a  remarkably  susceptible  condition  of  the  entire  spinal  system.  In  this 
condition  of  exalted  nervous  irritability  the  spinal  cord  is  especially  suscep- 
tible to  sudden  changes  in  the  surface  temperature,  as  by  a  sudden  cooling  of 
the  overheated  surface.  Statistics  as  to  the  relative  frequency  of  anterior  polio- 
myelitis during  this  period  have  been  compiled  by  various  observers;  accord- 
ing to  Gowers,  of  all  the  cases  under  ten  years,  three-fifths  occur  during  the 
first  two  years  and  four-fifths  during  the  first  three  years.  Of  71  cases  collected 
by  Seeligmliller,  90  per  cent,  occurred  before  three  years;  of  70  cases  collected 
by  Galbraith,  55  occurred  before  the  third  year;  of  350  cases  collected  by 
Sinkler,  in  335  of  which  the  age  of  the  patient  was  noted  at  the  onset  of  the 
attack,  247  occurred  under  three  years,  and  the  average  age  of  the  attack  was 
two  years,  one  month,  and  two  and  one-fifth  days;  and  of  115  cases  collected 
by  Starr,  54  occurred  before  three  years  and  i  before  the  fourth  year.  In  a 
tabulation  of  the  cases  collected  by  these  five  observers,  Starr  finds  that  472 
out  of  609  cases,  or  77  per  cent.,  occur  before  the  fourth  year,  420,  or  60  per 


INFANTILE  SPINAL  PARALYSIS.  605 

cent.,  before  the  third  year.  Of  83  cases  collected  by  Schultze,  there  were  n 
during  the  first  year,  31  during  the  second  year,  and  3  over  five  years,  and  in  250 
cases  collected  by  Heine,  Duchenne  the  younger,  and  Barlow,  1 54  were  between 
six  months  and  two  years.  One  case  occurred  at  sixty-three.  Sex  appears  to 
have  no  influence  whatever  upon  its  production,  although  it  is  stated  by  some 
writers  that  boys  are  more  frequently  attacked  than  girls,  especially  after  the 
tenth  year.  Of  the  345  cases  recorded  by  Sinkler,  184  were  boys  and  161  were 
girls,  and  of  the  63  cases  collected  by  Barlow,  2)2>  were  males  and  30  were 
females.  The  disease  appears  also  to  be  almost  as  frequent  among  the  children 
of  the  wealthy  as  among  those  of  the  poor,  and  Buzzard  thinks  "it  is  more 
common  than  not  for  the  disease  to  attack  fine,  grown,  hearty  children." 

Heredity  does  not  seem  to  have  any  influence,  and  cases  in  which  more 
than  one  individual  is  affected  in  the  same  family  appear  usually  to  be  the 
result  of  an  epidemic,  as  in  that  reported  by  W.  Pasteur  in  1896,  in  which  seven 
members  of  the  same  family  were  affected ;  although  Gowers  states  that  he  has 
"been  strongly  impressed  by  two  or  three  cases  in  which  other  members  of  the 
family  have  suffered  from  other  affections  of  the  nervous  system";  and  Sinkler 
also  refers  to  the  history  of  nervous  diseases  in  the  family,  especially  chorea.  In 
adult  cases  there  are  sometimes  the  history  of  hemiplegias,  etc.,  in  the  same 
family. 

Long-continued  ill  health  seems  to  have  no  causative  influence  on  the  dis- 
ease; but  a  number  of  cases  are  noted  where  the  attack  occurred  during  con- 
valescence from  some  one  of  the  acute  exanthemata,  as  scarlet  fever,  measles, 
rheumatism,  chorea,  whooping-cough,  cholera  infantum,  typhus  and  typhoid 
fever,  pneumonia,  variola,  and  grippe. 

It  occurs  with  equal  frequency  in  city  and  country,  although  the  affec- 
tion seems  rare  in  some  parts  of  the  country,  as  in  the  locality  in  Ireland  where 
during  a  period  of  thirty  years  not  a  single  case  has  been  met,  nor  are  there  any 
adults  known  in  the  district  who  are  cripples  in  consequence  of  the  disease. 
On  the  other  hand,  some  localities  are  prone  to  recurrent  epidemics. 

The  most  conspicuous  factor  in  the  causation  of  this  disease  in  children 
is  the  season  of  the  year — a  fact  first  emphasized  by  Sinkler  some  years  ago.  In 
the  350  cases  quoted  by  this  authority,  in  270  the  season  in  which  the  attack 
took  place  was  recorded;  of  these,  there  were  213,  or  78.8  per  cent.,  attacked 
in  the  hot  months  of  the  year — that  is,  from  May  to  September,  inclusive. 


606  ORTHOPEDIC  SURGERY. 

TABLE.— (P'rom  Sinkler.) 

Cases. 

\  March, 9 

c,  .                                                           ]  April,  4 

ii  prill  e,  27  cases, i  ,, 

^      *'     '                                                    May, 10 

[  Month  not  stated, 4 

f  Tune, 27 

„                                                       July, 52 

Summer,  174  cases 'i    »          ,  i. 

'     '                                              I  August, 65 

[  Month  not  stated, 30 

r  September, 29 

'  October, 24 

Aiilumn,  ?9  cases, \  ..  , 

•^^                                            I  November, 4 

I  Month  not  stated, i 

r  December, 3 

Winter,  10  cases, -j  January, 4 

L  February, 3 

Total, 270 


A  similar  table  has  also  been  more  recently  compiled  by  Starr,  consisting  of  452 
cases,  327,  or  over  72  per  cent.,  of  which  occurred  during  June,  July,  August,  and 
September;  116,  or  a  trifle  less  than  4  per  cent,  of  the  whole  number,  occurring 
during  August.  It  will  be  observed  that  the  greatest  number  occur  during 
August,  when  the  temperature  is  but  little  lower  than  in  July — a  fact  explained  by 
Sinkler  in  two  ways:  "  First,  because  the  intense  heat  of  July  has  prostrated  the 
children  to  such  an  extent  that  they  more  readily  succumb  to  the  spells  of  heat 
which  follow;  and,  secondly,  in  August  the  relative  humidity  is  greater  than 
in  July,  the  figures  being  72.1  per  cent,  and  68.6  per  cent,  respectively." 
Gowers  states  that  two-thirds  of  his  cases  were  attacked  between  June  and 
September,  and  Barlow,  27  out  of  53  of  whose  cases  were  attacked  during  July 
and  August,  confirms  his  observation.  The  degree  of  humidity  does  not, 
according  to  Sinkler,  show  any  influence  on  the  number  of  cases  unless  asso- 
ciated with  heat,  nor  does  the  range  of  temperature  have  any  eft"ect.  When 
cold  is  the  cause,  it  is  usuaUy  after  unusual  heat. 

Exposure  to  great  heat,  long  exposure  to  the  sun,  and  great  fatigue 
from  over-exercise,  whether  sudden  or  prolonged,  are  mentioned  as  causes 
of  the  attack.  Exposure  to  cold  and  sudden  chHltng  of  the  overheated 
body,  as  sitting  on  a  stone  step,  sleeping  in  a  newly  built  house,  plunging 
into  icy  water  after  violent  exercise, — as  in  cases  of  the  writer's,  or  as 
in  another  case,  the  cold-pack  being  used  to  prevent  "a  cold"  after  a 
child's  accidental  fall  into  a  lake  in  Switzerland, — or  Iving  or  sitting  on  the 


INFANTILE  SPINAL  PARALYSIS.  607 

damp  grass,  undoubtedly  have  a  marked  influence  upon  the  production  of 
the  disease. 

The  exact  relationship  between  digestive  disturbances  and  the  occurrence 
of  anterior  poliomyelitis  is  difficult  of  determination,  as  the  attack  at  times 
occurs  with  an  initial  vomiting  and  gastric  crisis. 

Cases  are  frequently  attributed  to  a  fall,  and  traumatic  hemorrhage  into  the 
substance  of  the  cord,  and  symptoms  resembling  this  affection  may  and  do 
occur;  but  in  the  majority  of  cases  in  children,  inasmuch  as  falling  is  ordinarily 
a  common  symptom  of  the  onset,  and  the  interval  between  the  particular  fall 
and  the  onset  of  the  disease  is  great,  the  association  is  of  no  importance. 

The  epidemic  and  endemic  occurrence  of  outbreaks  of  this  disease  would 
lend  color  to  the  exciting  cause  being  microbic.  Attempts  have  been  made 
to  isolate  a  microbe  in  this  disease,  but  as  yet  have  been  without  definite  success. 
An  analogy  between  this  disease  and  the  infectious  eruptive  disorder  accom- 
panied by  paralysis  which  affects  puppies,  "maladie  des  jeunes  chiens,"  in  which 
a  microbe  has  been  demonstrated,  was  pointed  out  by  Mathis  in  1887.  Schultze 
made  a  lumbar  puncture  on  the  thirteenth  day  from  the  onset  of  the  disease 
in  a  boy  of  five  and  succeeded  in  isolating  in  the  spinal  fluid  a  micro-organism 
which  he  named  the  Weichselbaum-Jager  diplococcus.  This  boy  afterward 
presented  typical  symptoms  of  infantile  spinal  palsy,  but  as  a  somewhat  like 
form  of  paralysis  occasionahy  follows  cerebrospinal  meningitis,  there  remains 
some  confusion  regarding  this  discovery. 

The  earliest  epidemic  observed  occurred  in  1843.  But  for  many  years 
after  that  they  were  not  reported.  In  1887,  Medin  reported  44  cases  occurring 
during  that  summer  in  Stockholm,  Sweden,  with  three  deaths;  in  1890,  Briegleb 
reported  at  the  Jena  Congress  an  epidemic  which  he  had  observed;  in  1894 
Caverly  reported  an  epidemic  occurring  in  Rutland,  Vermont,  in  which  out 
of  132  cases — in  some  of  which  the  cerebral  tracts  were  involved — there  were  18 
deaths  (the  cases  occurred  from  June  to  September,  and  domestic  animals 
also  suffered);  in  1894  J.  J.  Putnam  reported  an  epidemic  which  occurred 
near  Boston;  in  Australia,  in  1897,  an  epidemic  was  reported  by  Alston  of  14 
cases;  Madison  Taylor,  about  the  same  time,  reported  7  cases,  one  of  which 
was  fatal,  occurring  in  Cherryfield,  Maine.  Pasteur  reported  7  cases  in  one 
family  in  1896;  but  of  all  reports  of  epidemics,  Brackett's  report  of  the  epidemic 
in  North  Adams,  Massachusetts,  of  10  cases,  which  occurred  at  this  time, 
emphasizes  most  particularly  the  epidemic  peculiarities;  namely,  the  greater 
severity  of  all  symptoms,  the  fever  being  higher,  the  palsy  more  extensive,  the 


60S  ORTHOPEDIC  SURGERY. 

sphincters  at  times  being  paralyzed,  and  there  being  a  hyperesthesia  in  the 
severer  cases  which  was  longer  in  duration  and  more  pronounced  than  usual. 
There  was  but  one  etiologic  condition  common  to  all  these  cases;  namely,  the 
residence  of  all  but  one  of  these  patients  being  situated  along  the  river  banks. 

In  the  epidemic  reported  by  D.  H.  Mackenzie,  which  occurred  in  Dutchess 
County,  N.  Y.,  in  1899,  there  were  30  cases  within  ten  miles,  ten  of  which 
he  treated,  the  disease  being  particularly  fatal  in  adults. 

In  1903  there  was  but  one  epidemic  reported,  and  that  occurred  in  Cali- 
fornia, being  reported  by  Woods.  In  1904  there  was  an  epidemic  reported 
by  Lorenzelli,  of  Naples,  and  also  one  reported  by  Litchfield  and  Wade,  which 
occurred  in  Australia. 

In  conclusion,  primary  dentition  may  be  considered  a  frequent  predisposing 
cause,  and  sudden  chilling  of  the  overheated  body  surface  during  the  season 
of  the  year  when  the  relative  humidity  is  greatest  the  most  common  exciting 
cause.  In  other  words,  there  is  a  disturbance  of  the  thermotaxic  mechanism 
in  a  previously  weakened  subject,  the  peripheral  irritation  of  the  sympathetic 
and  other  spinal  nerves  causing  thereby  the  peculiar  cord  lesion  characteristic 
of  anterior  poliomyelitis.  The  theory  of  a  microbic  origin  would  seem  from 
the  acute,  epidemic,  and  endemic  occurrence  of  the  disease  to  be  tenable,  but 
more  exact  research  is  needed  to  render  this  theory  positive. 

Pathology. 

The  morbid  process  of  anterior  poliomyelitis  consists  of  an  acute  destructive 
inflammatory  lesion,  mainly,  though  not  exclusively,  confined  to  the  large 
multipolar  cells  of  the  anterior  cornua  in  the  gray  matter  of  the  spinal  cord 
and  their  neuraxons  passing  out  through  the  anterior  roots,  and  the  secondary 
degeneration  and  destruction  of  nerve-cells  and  marked  changes  in  the  peripheral 
nerves.  In  some  severe  cases  there  is  a  dorsal  involvement,  but  in  the  large 
majority  of  cases  the  disease  is  confined  to  the  cervical  and  lumbar  enlargements 
of  the  cord. 

The  exhaustive  researches  of  Charot  and  Joffroy  and  the  autopsies  performed 
by  Drummond,  Damaschino,  Charlewood  Turner,  and  Ashby  in  children, 
and  in  adults  the  researches  by  Bernhardt,  Cornil  and  Lepine,  Williamson, 
Mednir,  Jagic,  Caverly,  and  in  very  recent  years  by  Taylor  and  Spiller,  have 
established  beyond  cavil  the  exact  nature  and  location  of  the  lesion. 

There  has  been,  however,  much  dispute  as  to  the  hematogenous  or  neuro- 
genous origin  of  the  affection;    Goldscheide  and  Seimerling  especially  being 


INFANTILE  SPINAL  PARALYSIS. 


609 


instrumental  in  the  present  acceptance  of  the  view  that  the  blood-vessels  are 
first  affected.  In  favor  of  this  view  are  the  great  vascular  changes,  and  the 
fact  that  the  nearer  the  ganglion  cells  are  to  the  blood-vessels,  the  more  are 
they  degenerated,  and  also  that  it  is  not  the  cells  of  a  definite  group  but  those 
supplied  by  a  certain  blood-vessel  or  vessels  which  are  affected. 

The  primary  lesion  is  an  inflammation  which  spreads  over  the  greater 
portion  of  the  cord,  but  is  more  intense  in  the  cervical  and  lumbar  enlargements, 
particiilarly  in  the  anterior  cornua,  the  most  vascular  part  of  the  cord,  and  also 
in  the  anterior  commissure,  and  the  anterior  septum.  The  most  striking 
microscopic  change  observed  is  that  present  in  the  blood-vessels;  they  are 
greatly  engorged  and  surrounded 
by  leukocytes.  The  neurogliar 
tissue  is  loosened,  and  there  is 
more  or  less  cellular  infiltration 
throughout,  the  cells  being  fre- 
quently grouped  and  mainly 
mononuclear.  In  the  white 
matter  leukocytes  occur,  but 
not  in  any  great  quantities. 
The  exudation  of  leukocytes 
leads  to  both  temporary  and 
permanent  damage  to  the  motor 
cells  in  this  region ;  even  in  cases 
examined  a  few  days  after  the 
onset  the  number  of  ganglion 
cells  is  markedly  diminished, 
showing  that  some  of  them  have 

undergone  complete  degeneration.  The  cells  may  be  swollen  and-  colorless,  con- 
taining chromatin  granules  in  irregular  masses,  irregular  processes  and  nucleus 
displaced  and  staining  deeply,  with  vacuolar  degeneration  of  the  nucleolus. 
Later  both  the  nucleus  and  protoplasmic  processes  disappear,  leaving  only  the 
enlarged  axis-cylinder  springing  from  the  cell.  In  the  perivascular  spaces  round 
cells  are  frequently  found  with  great  distention  of  the  space.  The  nerve-fibers  of 
the  anterior  roots  degenerate,  the  sheaths  soon  containing  fatty  globules  and  the 
axis-cylinders  swelling  and  disintegrating.  When  the  inflammation  subsides, 
absorption  of  the  exudate  occurs,  and  a  gradual  improvement  takes  place  in 
those  areas  where  the  destruction  of  the  gray  matter  has  been  incomplete. 


Fig.  444. — Acute  Poliomyelitis  in  Adult,  showing  Dis- 
tribution OF  Round-cell  Infiltration  within  the 
Gray  and  White  Matter  (Spiller). 


610  ORTHOPEDIC  SURGERY. 

Marinesco  has  described  a  process  of  restitution  of  the  injured  cells,  accounting 
for  the  regaining  of  a  certain  amount  of  muscular  power. 

In  cases  examined  years  or  months  after  the  onset  of  the  paralysis  there 
is  evidence  of  secondary  sclerotic  changes,  the  destroyed  areas  in  the  anterior 
cornua  being  replaced  by  cicatricial  connective  tisue.  The  comua  are  markedly 
diminished  in  size,  but  usually  unequally  so,  one  horn  being  not  infrequently 
normal  or  presenting  only  slight  alterations,  while  the  other  is  markedly 
diminished  and  the  columns  of  Clark  disappear.     Occasionally  there  is  a  colloid 


Fig.  445. — Poliomyelitis  in  Adult  of  Sixty  Years. 

degeneration  of  the  cornua.  The  blood-vessels  are  dilated  and  their  walls 
thickened,  and  the  debris  of  degeneration,  corpora  amylacese,  pigment  granules, 
etc.,  are  abundant.  The  large  ganglion  cells  are  in  different  stages  of  degenera- 
tion and  atrophy  or  are  entirely  absent.  There  is  hyperplasia  of  the  neuroglia, 
it  being  a  coarse  network  containing  large  numbers  of  nuclei.  The  medullated 
fibers  of  the  anterior  roots  are  destroyed  wholly  or  in  part.  Degeneration  of 
the  fibers  of  the  pyramidal  tracts  may  be  found  occasionally  for  a  few  segments 
above  the  main  lesion,  but  is  usually  slight.  Degenerative  changes  take  place 
likewise  in  the  peripheral  nerves  connected  with  the  damaged  cord ;  the  muscles 


INFANTILE  SPINAL  PARALYSIS. 


611 


waste;  their  fibrillar  structure  is  replaced  by  fat  globules,  and  finally  the  muscular 
tissue  loses  its  identity;  and  there  is  an  absence  of  even  fat-globules,  the  fat  being 


Fig.  446. — Poliomyelitis  in  Adult,  after  Smallpox  (Spiller). 


replaced  by  hypertrophied  connective  tissue.    According  to  Barlow,  a  muscle 
may,  however,  be  much  wasted  in  bulk  without  these  microscopic  changes  being 


612  ORTHOPEDIC  SURGERY. 

present.  The  muscles  which  oppose  these  paralyzed  muscles  are  much  wasted 
from  disuse;  the  arteries  are  diminished  in  size;  the  tendons  are  elongated 
and  atrophied,  and  the  growth  and  development  of  the  bones  is  greatly  retarded 
— so  that  there  may  be  several  inches  shortening,  the  medullary  portion  being 
increased.  Changes  also  occur  in  the  articulations,  the  articular  extremities 
of  the  bones  often  being  atrophied,  the  cartilages  thin  and  sometimes  eroded. 
These  changes  are  all  atrophic. 

Symptoms. 

This  affection  occurs  in  two  forms:  the  acute  and  the  subacute  or  chronic. 
The  former,  occurring  most  frequently  in  children  and  being  the  most  fruitful 
of  deformities,  will  be  the  only  one  considered.  This  disease  is  usually  seen 
by  the  orthopedic  surgeon  when  atrophy,  crippling  deformities,  and  contractures 
present  a  comprehensive  picture  of  the  chronic  stage;  but  to  appreciate  this 
affection  thoroughly,  it  is  necessary  to  study  the  early  stages  also.  The  course 
of  the  disease  is  most  conveniently  divided  into  four  stages:  (i)  the  initial 
stage;  (2)  stationary  period,  which  lasts  from  a  day  to  a  month;  (3)  a  period 
of  "regression,"  which  lasts  from  one  to  six  months,  during  which  the  motor 
function  returns  to  certain  of  the  affected  muscles;  (4)  a  chronic  stage,  during 
which  the  degenerative  changes  and  contractures  occur,  and  during  which 
slight  and  gradual  improvement  may  intervene  at  any  period. 

I.  The  initial  stage,  or  stage  of  invasion,  may  be  characterized  by  a  sudden 
paralysis,  without  any  prodromal  symptoms,  but  it  is  usually  ushered  in  with 
moderate  fever  (102°  F.),  general  irritability,  aching  pains  in  the  loins,  joints, 
and  limbs,  convulsions,  vomiting,  diarrhea,  muscular  twitchings,  and  great 
cerebral  disturbance — headache,  drowsiness,  or  even  stupor.  Multiple  neuritis 
may  be  associated,  and  may  form  an  aggravating  complication  by  its  persistence. 
These  symptoms  are  usually  overlooked  by  the  friends,  or  attributed  to  dentition 
or  general  gastro-intestinal  disorder,  and  it  is  not  until  the  paralysis  supervenes 
that  the  importance  of  these  symptoms  is  recognized,  and  frequently  the  patient 
becomes  convalescent  and  attempts  to  rise  before  even  the  paralysis  is 
distinguished. 

The  pyrexia,  though  rarely  high,  may  reach  105°  or  106°  F.  The  general 
cerebral  disturbance  is  so  marked  as  to  have  been'a'.tributed  to  meningitis,  by 
both  the  layman  and  the  practitioner. 

The  paralysis  usually  reaches  its  height  at  once,  or  in  a  very  few  days — 
occurring  within  the  first  three  davs  of  the  beginning  of  the  general  constitu- 


INFANTILE  SPINAL  PARALYSIS.  613 

tional  disturbance.  A  single  group  of  muscles  only  may  be  paralyzed,  or  the 
paralysis  may  be  monoplegic  from  the  onset,  but  usually  the  paralysis  affects 
all  the  extremities  at  the  onset  and  rapid  regression  takes  place.  The  severity 
of  the  initial  attack  seems  to  have  no  effect  upon  the  extent  of  the  paralysis 
which  follows,  since  some  of  the  most  extensive  and  complete  paralyses  have 
supervened  after  the  mildest  initial  stage.  The  paralysis  is  monoplegic  in 
its  distribution  in  nearly  half  the  cases,  and  is  much  more  frequent  in  the  lower 
than  in  the  upper  extremity.  The  relative  distribution  of  the  paralysis  is  well 
shown  in  the  following  table  from  Starr: 

DucHExxE.     Seeligmuller.  Sinkler.  Starr.  Total. 

Both  legs, 9  14  107  40  170 

Right  leg, 25  IS  63  20  123 

Left  leg, 7  27  62  27  123 

Right  arm, 5  9  5  7  26 

Left  arm, 5  4  8  4  21 

Both  arms, 2  1  i  2  6 

All  extremities, 5  2  35  5  47 

Arm  and  leg,  same  side, i  2  26  4  33 

Arm  and  leg,  opposite  sides, ...  2  i  i  4  8 

Trunk, i  o  22  3  26 

Three  extremities, o  o  10  2  12 

62  75  340  118  595 

The  muscles  most  frequently  paralyzed  are  those  of  one  lower  extremity, 
particularly  those  of  the  leg.  Muscles  of  the  trunk  are  only  affected  in  the 
severer  grades  of  paralysis,  and  paralysis  of  the  sphincters  of  the  bladder  and 
rectum  is  exceedingly  rare.  When  single  muscles  are  affected,  the  deltoid 
suffers  alone  more  frequently  than  any  other  muscle  of  the  arm,  and  the  tibialis 
anticus  is  paralyzed  alone  oftener  than  other  muscles.  The  flexors  of  the  foot 
and  the  extensors  of  the  leg  are  next  in  the  order  of  frequency.  Paralysis  of 
the  facial  muscles  is  rare,  though  cases  have  been  observed  by  the  author. 
Fortunately,  certain  muscles  always  escape  paralysis,  as  the  muscles  of  the 
eyeballs,  ears,  larynx,  and  those  of  respiration;  the  diaphragm  and  intercostals 
are  only  affected  in  the  most  exceptional  instances.  Universal  paralysis,  when  it 
occurs,  according  to  my  observations,  is  quickly  fatal  from  failure  of  respiration. 

2.  The  stationary  or  paralytic  stage  is  characterized  by  a  period  of  from 
one  to  six  weeks,  or  even  four  months,  during  which  the  muscle  paresis  remains 
stationary.  The  muscular  paralysis  may  be  limited  to  one  or  both  arms  or 
legs,  to  one  arm  and  the  opposite  leg  (crossed  paralysis),  or  to  definite  groups 
of  muscles,  according  to  the  extent  of  the  nerve-cell  involvement.     The  bladder 


614 


ORTHOPEDIC  SURGERY. 


and  rectum  remain  uninvolved.    As  a  rule, ,  however,  the   regression  occurs 
early,  the  first  improvement  usually  taking  place  in  the  parts  last  affected, 
and  extending  until  all  the  muscles  have  recovered,  except  those  which  are  to 
remain  permanently  paralyzed.    The  reflexes,  both  superficial  and  deep,  are  lost. 
Sensation  usually  is  not  affected,  but  in  rare  cases  it  may  be  diminished  and 
even  entirely  lost.     If,  however,  multiple  neuritis  complicates  the  paralysis, 
severe  hyperesthesia  is  associated.      The  circulation  in  the  skin  is  interfered 
with  by  the  cord  lesion,  and  the  temperature  of 
the  part  affected  is  much   reduced,  there  being 
frequently  two    or  three   degrees  difference   be- 
tween the  healthy  and  the  affected  limb,  and  in 
exceptional  cases  io°,  20°,  30°,  or  even  40°.     The 
circulation  is  sluggish,  giving  rise  to  a  mottled, 
dusky  purplish  discoloration  of  the  skin;  the  skin 
is  easily  excoriated  under  friction,  but  is  free  from 
idiopathic  ulcerations,  sloughs,  or  severe  atrophic 
changes.      The    muscle   irritability    is    markedly 
changed  during  this  early  period,  the  reaction  to 
the  faradic  current  being  usually  entirely  absent 
in  those  muscles  that  are  permanently  paralyzed. 
The  muscle  irritability  to  the  continuous  cur- 
rent during  this  period  is  increased,  but  becomes 
gradually  lessened  later,  and   may  entirely  dis- 
appear.     To  the  continuous  galvanic  current  it 
stUl   continues   to  respond,  though    the  reaction 
differs  essentially  from  that  of  healthy  muscles, 
the  change  being  the  so-called  "reaction  of  de- 
generation," due  to  the  degeneration  of  the  peri- 
pheral nerves.     The  electric  formula  is  reversed, 
a  change  to  be  referred  to  later  under  diagnosis. 
3.  The  stage  of  regression,  commencing  after 
two  or  three  days,  or  after  a  delay  of  three  or  four  months,  continues  till  all 
the  muscles  have  regained  their  power  except  those  which  are  to  remain  per- 
manently paralyzed.     This  includes  a  period  which  terminates  only  with  the 
cessation  of  growth  itself. 

Recovery  in  the  affected  muscles  is  indicated  by  an  increased  response  to 
the  interrupted  current,  whUe  a  diminished  response  and  progressive  atrophy 
mark  the  advance  of  permanent  paratysis  in  the  muscles  which  are  to  remain 


Fia.  447. — Photograph  of  Sf- 
VERE  Case  of  Infantile 
Spinal  Paralysis. 


INFANTILE  SPINAL  PARALYSIS. 


615 


permanently  affected.  This  gradual  regression  of  the  original  paralysis  is  a 
remarkable  clinical  observation,  in  a  few  instances  entire  recovery  occurring 
in  all  the  affected  muscles,  and  in  others  recovery  ensuing  after  one  or  more 
attacks  and  permanent  paralysis  finally  resulting.  During  this  period  of  regres- 
sion the  general  health  is  usually  excellent,  all  the  bodily  functions  are  per- 


FiG.  448. — Infantile  Paralysis,  showing  Attitude  in  Walking. 


fectly  performed,  the  child  appears  perfectly  well,  and  nothing  but  the  paralysis 
and  atrophy  remain  to  indicate  the  inflammatory  stage  passed. 

4.  The  chronic  stage,  characterized  by  deformities  and  dislocations  from 
atrophy  and  contractures,  is  of  peculiar  interest  to  the  orthopedic  surgeon. 
Six  months  after  the  onset  of  the  disease  marks  the  limit  of  rapid  improvement, 
and  the  improvement,  which  may  go  on  for  years,  is  always  slow  and  very  slight 
after  this  period.     At  this  time  may  be  estimated  pretty  accurately  the  amount 


616  ORTHOPEDIC  SURGERY. 

and  distribution  of  the  permanent  paralysis,  which  is  always  much  less  than  at 
first  appeared.  This  permanent  paralysis  may  afltect  only  a  single  muscle  or 
may  include  the  muscles  of  all  the  extremities  and  some  of  the  trunk  muscles. 

The  symptoms  of  the  paralysis  of  individual  muscles  and  groups  of  muscles 
produced  by  paralysis  of  their  motor  nerves  are  well  illustrated  in  the  follow- 
ing original  schedule : 

Cervical  Nerves. — Paralysis  of  the  anterior  division  of  the  third  and  fourth 
cervical  nerves  causes  paralysis  of  the  trapezius,  as  does  also  paralysis  of  the 
spinal  accessory,  causing  droop  of  the  point  of  the  shoulder  and  a  falling  back 
of  the  head. 

Posterior  Thoracic— VaxaXysi?,  of  the  serratus  magnus  causes  a  down- 
ward and  backward  falling  of  the  vertebral  border  of  the  scapula. 

Upper  Extremity. — Suprascapular  Nerve. — Paralysis  of  the  suprascapular 
nerve  causes  paralysis  of  the  supraspinatus  and  infraspinatus  muscles,  as 
shown  by  the  inability  to  perform  external  rotation  of  the  humerus,  and  paralysis 
of  the  upper  and  lower  subscapularis  interferes  with  the  inward  rotation  of  the 
humerus  through  paralysis  of  the  subscapular  muscles. 

Circumflex. — Paralysis  of  the  circumflex  causes  paralysis  of  the  deltoid 
and  teres  minor  muscles,  as  shown  by  a  flattening  of  the  shoulder  with  an  ex- 
aggerated prominence  of  the  acromion,  inability  to  abduct  the  arm,  and  some- 
times a  subluxation  of  the  humerus.  Paralysis  of  the  brachialis  anticus, 
biceps,  and  supinator  longus  is  often  associated. 

Musculospiral. — Paralysis  of  the  musculospiral  causes  paralysis  of  the 
triceps  and  all  the  muscles  on  the  posterior  aspect  of  the  forearm,  especially 
the  extensors  of  the  wrist  and  fingers  and  the  supinators,  causing  "wrist-drop" 
and  inability  to  supinate  the  forearm  or  extend  the  elbow  voluntarily. 

Lower  Extremity. — Anterior  Branches  of  Lumbar  Nerves. — Paralysis  of 
the  anterior  branches  of  the  lumbar  nerves  causes  paralysis  of  the  iliopsoas 
muscle,  causing  inability  to  flex  the  thigh.  The  leg  remains  extended  if  the 
glutei  are  intact.     This  condition  is  rare  except  in  general  paralysis. 

Gluteal. — Paralysis  of  the  gluteal  nerve  causes  paralysis  of  the  glutei, 
causing  flattening  of  the  buttocks,  and  inability  to  abduct  and  circumduct  the 
thigh. 

Anterior  Crural. — Paralysis  of  the  anterior  crural  nerve  causes  paralysis 
of  the  quadriceps  extensor  femoris,  as  shown  in  the  adduction  of  the  leg, 
flexion  of  the  knee,  and  inability  to  extend  the  knee. 

Anterior  Tibial. — Paralysis  of  the  anterior  tibial  nerve  causes  paralysis 


INFANTILE  SPINAL  PARALYSIS.  617 

of  the  tibialis  anticus,  extensor  proprius  pollicis,  extensor  longus  and  brevis 
digitorum,  and  peroneus  tertius,  causing  talipes  equinus,  toes  flexed,  and  drag- 
ging on  ground  in  walking,  with  hollow  sole  of  foot.  If  only  the  tibialis 
anticus  muscle  is  involved,  the  foot  would  be  in  slight  valgus. 

Musculocutaneous. — Paralysis  of  the  musculocutaneous  nerve  causes  par- 
alysis of  the  peroneus  brevis  and  the  peroneus  longus,  causing  talipes-varus 
and  pes  planus. 

Internal  Popliteal  and  Posterior  Tibial. — Paralysis  of  the  internal  popliteal 
and  posterior  tibial  nerves  causes  paralysis  of  the  muscles  of  the  calf,  tibialis 
posticus,  flexor  longus  digitorum,  flexor  longus  haUucis,  causing  talipes  cal- 
caneous  cavus,  inability  to  extend  ankle-joint  and  adduct  foot,  and  hyper- 
extension  of  the  distal  phalanges  of  the  toes. 

Dorsal  and  Lumbar. — Paralysis  of  the  posterior  division  of  the  dorsal  and 
lumbar  nerves,  if  bilateral,  causes  paralysis  of  the  extensors  of  the  back,  caus- 
ing inability  to  extend  the  back,  hence  a  constant  maintenance  of  the  body 
in  a  position  of  lordosis,  and  a  projection  backward  of  the  shoulders.  If  the 
paralysis  is  unilateral,  scoliosis  is  produced. 

Paralysis  of  the  anterior  division  of  the  dorsal  and  lumbar  nerves  causes 
paralysis  of  the  abdominal  muscles,  causing  lordosis  without  projection  back- 
ward of  the  shoulders. 

The  deformities  resulting  from  infantile  paralysis  have  been  ascribed  to 
one  of  three  causes:  (i)  the  relaxation  of  the  muscles  and  ligaments,  and  the 
undue  action  of  their  opponents;  (2)  the  result  of  growth  upon  the  limb,  the 
paralyzed  parts  remaining  undeveloped;  and  (3)  stretching  of  the  paralyzed 
muscles  at  the  onset  of  the  paralysis.  The  first  cause — the  unequal  action  of 
the  muscles — undoubtedly  has  its  influence  in  certain  instances,  and  is  an  impor- 
tant factor  in  the  production  of  deformity,  particularly  where  a  single  muscle 
or  group  of  muscles  is  involved;  but  the  second  cause — that  they  are  due  to 
atrophy  and  arrest  of  growth — is  by  far  the  most  important,  and  as  such  de- 
serves emphasis.  Nearly  all  these  deformities  may  be  accounted  for  on  purely 
mechanical  grounds.  It  has  been  demonstrated  that  the  weight  of  the  part 
in  the  position  assumed  at  rest  in  paralysis,  and  the  muscular  insufficiency  of 
the  affected  parts,  which  subjects  the  articular  surfaces  to  excessive  pressure 
when  in  use,  cause  the  deformities. 

Thus  in  paralysis  of  the  muscles  of  the  anterior  region  of  the  leg  the  de- 
formity is  due  entirely  to  the  force  of  gravity,  the  foot  falling  into  the  position 
of  equinus,  and  the  anterior  portion  of  the  foot  being  adducted  by  its  own  weight. 


618  ORTHOPEDIC  SURGERY. 

In  these  cases  in  the  early  stages  there  is  Httle  or  no  contraction,  and  the 
deformity  can  be  readily  reduced  by  manual  pressure.  Attention  has  also  been 
called  to  the  fact  that  the  abnormal  position  assumed  by  the  affected  limb  even- 
tually becomes  permanent  through  the  weight  of  the  body  and  abnormal  growth, 
and  not,  as  was  formerly  assumed,  from  contraction.  The  apparent  con- 
tractures which  are  met  in  this  affection,  as  the  muscles  about  the  hip,  knee, 
ankle,  and  foot,  are  not,  then,  due  to  contracture  of  these  structures,  but  are 
the  result  of  abnormal  or  normal  growth  of  the  bones  and  antagonizing  muscles; 
these  affected  structures,  from  paralysis  and  atrophy,  remaining  in  their  original 
condition.  This  corresponds  to  the  so-called  "adapted  atrophy,"  the  changes 
ensuing  in  consequence  of  the  mechanical  relations  of  the  foot  to  the  leg.  Thus, 
in  talipes  varus  resulting  from  infantile  paralysis  the  plantar  fascia  is  not  per  se 
contracted,  but  its  growth  being  retarded  or  abolished,  and  the  foot  growing 
in  length,  the  apparent  contracture  has  resulted.  Sometimes  the  paralysis 
causes  an  arrest  of  development  in  the  growth  of  the  bone,  producing  a  stunted 
appearance. 

3.  There  is  still  one  other  factor  at  work  which  has  been  suggested  as 
the  cause  of  the  more  severe  paralysis  of  certain  groups  of  muscles  over  others, 
as  in  the  anterior  muscles  of  the  thigh  and  leg,  and  this  is  the  stretching  of 
these  muscles  by  the  weight  of  the  foot  and  leg  in  Ijdng  and  sitting.  This 
stretching  of  the  muscles,  if  all  the  muscles  were  equally  affected  at  the  onset, 
is  sufficient  to  account  for  the  severe  paralysis  remaining  after  the  other  groups 
have  recovered. 

The  deformities  arising  from  infantile  paralysis  may  be  considered  under 
three  groups:  deformities  of  the  upper  extremity,  deformities  of  the  lower 
extremity,  and  deformities  of  the  trunk. 

Deformities  of  the  Upper  Extremity. — The  deltoid,  though  not  a  com- 
mon seat  of  paralysis,  suffers  alone  more  frequently  than  any  other  muscle  of 
the  upper  extremity.  In  addition  to  the  inability  to  raise  the  arm,  there  is  a 
loss  of  rotundity  in  the  shoulder,  and  a  prominence  of  the  acromion  process, 
the  shoulder  presenting  a  flattened  appearance,  and  sometimes  a  subluxation. 
Associated  with  paralysis  of  other  muscles — the  supraspinatus  and  infraspi- 
natus, biceps,  and  triceps — it  constitutes  the  so-called  "upper-arm  type"  of 
Erb,  a  combination  which  differs  from  the  "upper-arm  type"  of  Remak,  in 
which  the  supinator  longus  is  affected  along  with  the  brachialis  anticus,  biceps, 
and  deltoid.  The  trapezius,  subscapularis,  and  serratus  magnus  are  occa- 
sionally aft'ected. 


INFANTILE  SPINAL  PARALYSIS. 


619 


Paralysis  of  supinators  and  extensors  of  the  hand  and  the  adductors  of 
the  thumb,  when  it  occurs,  may  result  in  flexion  of  the  hand  and  fingers, 
with  restricted  mobility,  and  may  prevent  the  apposition  of  the  thumb  with 
the  other  digits.  When  the  supinator  longus  escapes,  but  the  extensors  of  the 
wrist  are  affected,  it  constitutes  the  so-called  "forearm  type"  of  Remak.  A 
deformity  amounting  to  club-hand  may  likewise  occur.  Contraction  of  the 
shoulder,  elbow,  and  wrist  resembles  post-hemi- 
plegic  contractures. 

Deformities  of  the  Lower  Extremity. — 
Paralysis  and  atrophy  may  affect  the'entire  limb, 
and  give  rise  to  the  withered,  useless,  flaU-like, 
doll-like  limb  known  as  "jambe  de  polichinelle," 
or  but  a  single  extensor  of  the  foot  may  be  in- 
volved, influencing  locomotion  but  little  or  not 
at  all.  Fortunately,  the  paralysis  is  more  fre- 
quently partial  than  complete. 

The  extensor  quadriceps  and  glutei  are  the 
muscles  most  frequently  affected  in  the  thigh. 
The  limb  flexed  and  adducted  cannot  be  made 
sufficiently  rigid  to  sustain  the  body-weight,  and 
extension  and  outward  rotation  are  lost. 

Contraction  of  the  sartorius,  tensor  vaginae 
femoris,  and,  in  rare  cases,  the'  iliopsoas  mus- 
cles, prevents  the  limbs  being  brought  under- 
neath the  body,  except  by  the  forward  rotation 
of  the  pelvis  and  the  production  of  marked 
lordosis  in  the  lumbar  region  of  the  back. 

Dislocation  of  the  hip  may  occur  spon- 
taneously from  relaxation  of  the  muscles  and 

ligaments,  or  may  result  from  the  weight  being  improperly  thrown  upon  it. 
Dislocation  upon  the  dorsum  of  the  Uium  is  the  most  frequent,  but  displacement 
in  other  directions  may  occur,  and  the  relaxation  of  the  joint  may  be  very  great. 
Shortening  and  great  mobility,  without  pain  or  other  symptoms,  characterize  the 
deformity,  and  if  the  dislocation  is  allowed  to  remain,  a  new  cavity  for  the  head 
of  the  bone  will  in  time  be  formed. 

At  the  knee-joint  inability  to  extend  the  knee  is  the  most  common  de- 
formity, and  great  laxity  with  lateral  mobility  may  occur.     Other  deformities 


Fig.    440. — Inf.intile    Spinal    Par- 
alysis.    MoNOPLEGic  Type. 


620 


ORTHOPEDIC  SURGERY. 


of  the  knee  arise  from  use  of  the  joint,  the  body  falling  improperly  upon  the 
relaxed  ligaments.  In  this  way  occur  the  hyperextension  of  the  knee,  or  recur- 
vation, in  which  the  knee  is  bent 
backward  beyond  the  perpen- 
dicular, and  the  head  of  the  tibia 
lies  in  a  plane  posterior  to  the 
line  of  the  femur. 

Permanent  flexion  from 
contraction  of  the  hamstring 
tendons  and  knock-knee  from 
elongation  of  the  internal  lateral 
ligament  result  in  severe  cases. 
Outward  rotation  of  the  tibia 
upon  the  condyles  of  the  femur 
results  from  undue  contraction 
of  the  biceps. 

The  most  frequent  varie- 
ties of  club-foot  are  equino-varus  and  valgus.  Equino-varus  results  from  par- 
alysis of  the  anterior  tibial  and  peronei  muscles.  If,  however,  the  peronei  remain 
intact,  equinus  results.  Talipes 
varus  is  rare,  and  talipes  cal- 
caneus is  the  rarest  of  all  the 
deformities  from  poliomyelitis. 
Talipes  valgus  acquisitus 
and  talipes  calcaneo-valgus  re- 
sult from  the  relaxation  of  the 
ligaments,  and  the  improper 
transmission  of  the  body-weight 
upon  the  ground,  and  the  most 
severe  forms  of  these  deformi- 
ties result  from  infantile  par- 
alysis. 


_  Fig.  450. — Infantile  Paralysis.    Paraplegic  Type. 


Fig.  451. — Inf.antile  P.\ralysis.     Paraplegic  Type. 


In     valgus     the     changes 
which  ensue  from  the   effects 

of  growth  upon  the  mechanical  relations  of  the  foot  to  the  leg  are  observed, 
and  in  severe  cases  contraction  of  the  peronei  tendons  is  noted.  Likewise  in 
varus,  contraction  of  the  plantar  fascia  is  of  frequent  occurrence. 


INFANTILE  SPINAL  PARALYSIS.  621 

True  talipes  calcaneus  almost  never  occurs,  and  its  existence  has  been 
doubted.  What  does  occur,  however,  is  known  as  pes  cavus.  The  heel  is 
lowered  by  relaxation;  the  anterior  part  of  the  foot  remaining  in  the  norma^ 
plane  gives  an  arched  appearance  to  the  sole  of  the  foot,  and  an  apparent  ele- 
vation of  the  anterior  portion  of  the  foot. 

These  deformities  occur  in  the  following  order  of  frequency:  (i)  Talipes 
equinus;  (2)  equino-varus ;  (3)  equino- valgus ;  (4)  calcaneo-valgus ;  (5) 
talipes  varus;  and  (6)  calcaneus.  When  both  feet  are  affected,  equino-varus 
of  one  foot  is  generally  found  with  equino-valgus  of  the  other. 

Deformities  of  the  Trunk. — Paralysis  of  the  trunk  muscles  in  severe 
cases  gives  rise  to  great  distortion  and  may  render  the  patient  perfectly 
helpless. 

Paralysis  of  the  extensors  of  the  back,  when  bilateral,  produces  lordosis 
on  standing,  inability  to  sit  erect,  and  projection  backward  of  the  shoulders. 
This  lordosis  is  produced  by  the  patient's  effort  to  maintain  his  equilibrium. 
If  flexion  occur,  voluntary  extension  Avould  be  impossible;  hence  extension  is 
constantly  maintained.  When  unilateral,  it  results  in  lateral  curvature,  with 
inability  to  move  the  trunk  toward  the  paralyzed  side. 

Paralysis  of  the  abdominal  muscles  produces  lordosis  also,  but  without 
backward  projection  of  the  shoulders. 

The  lateral  curvature  of  the  spine  resulting  from  infantile  paralysis  may 
be  either  (i)  static,  where  the  trunk  muscles  are  unaffected  but  where  the 
pelvis  is  tilted  from  inequality  of  one  lower  limb  from  paralysis  and  atrophy, 
or  where  faulty  spinal  attitudes  are  habitually  assumed  from  paralysis  and 
atrophy  of  the  muscles  of  one  upper  extremity,  or  (2)  paralytic,  from  unilateral 
paralysis  of  the  intrinsic  spinal  muscles,  that  important  group  which  controls 
the  movements  of  the  in-dividual  vertebras,  or  the  great  erector  spina;  mass  of 
muscles,  which  controls  the  movements  of  the  column  as  a  whole. 

Diagnosis. 

The  symptoms  in  well-established  infantile  paralysis  are  so  strikingly  pecu- 
liar that  a  diagnosis  is  not  difhcult,  and  yet  in  the  early  stages,  before  the  devel- 
opment of  the  paralysis,  a  correct  diagnosis  is  most  difficult  to  establish.  The 
pyrexia,  convulsions,  and  vomiting  are  frequently  mistaken  for  cerebrospinal 
meningitis,  acute  rheumatism,  acute  cold,  indigestion,  etc.,  and  the  paralysis 
which  ensues  is  often  mistaken  for  the  prostration  following  some  acute 
affection. 


622  ORTHOPEDIC  SURGERY. 

The  characteristic  symptoms  upon  which  the  practitioner  must  rely  for  a 
correct  estabhshment  of  a  diagnosis  are: 

1.  Sudden  onset. 

2.  Motor  paralysis  (sensation  unaffected),  tending  toward  regression. 

3.  Lost  or  diminished  reflexes. 

4.  Paralyzed  muscles  are  at  all  times  flaccid. 

5.  Change  of  electromotor  reaction. 

6.  Atrophy  and  deformities. 

It  should  be  recollected  that  the  prostration  following  acute  illness  never 
amounts  to  complete  loss  of  power,  and  that  reflex  irritation,  as  from  phimosis, 
ascarides,  and  similar  peripheral  irritations,  may  cause  some  of  the  symptoms, 
but  their  stationary  character,  and  subsidence  upon  removing  the  cause,  should 
make  the  diagnosis  clear. 

The  only  affections  which  cannot  be  differentiated  from  infantile  paralysis 
by  an  electric  examination  are  the  peripheral  palsies,  where  localized  paralyses 
result  from  traumatism  or  the  presence  of  an  enlarged  gland  or  tumor  on  a 
nerve — in  fact,  wherever  the  muscles  are  cut  off  from  the  influence  of  the  trophic 
centers. 

The  electric  reaction  of  the  muscles  furnishes  by  far  the  most  important 
diagnostic  test. 

For  the  following  practical  description  of  the  electric  reactions,  the  writer 
is  indebted  to  Dr.  Charles  S.  Potts,  Associate  in  Neurology  in  the  University 
of  Pennsylvania. 

One  of  the  most  important  symptoms  of  acute  poliomyelitis  is  the  changed 
behavior  of  the  affected  muscles  and  the  nerves  supplying  them,  when  stimu- 
lated by  the  electric  current.  This  change  is  present  to  a  greater  or  less  degree 
whenever  a  muscle  or  nerve  is  cut  off  from  its  trophic  center,  and  has  been 
termed  by  Erb  the  reaction  of  degeneration.  In  order  to  more  fully  compre- 
hend what  this  alteration  is,  a  brief  account  of  how  the  muscles  and  nerves  act 
when  normal  may  not  be  out  of  place. 

1.  Response  to  the  faradic  current.  When  one  of  the  electrodes  is  placed 
either  over  the  muscle  or  the  nerve  supplying  it,  the  other  being  placed  at  some 
indifferent  point,  there  is  a  contraction  of  the  muscle  at  each  opening  and  closure 
of  the  circuit. 

2.  Response  to  the  galvanic  current.  If  the  negative  pole,  termed  the 
cathode,  is  placed  over  the  nerve  and  the  other  at  some  indifferent  point,  the 
sternum  preferably,  and  the  current  is  gradually  increased   in   strength  and 


INFANTILE  SPINAL  PARALYSIS.  623 

the  circuit  alternately  opened  and  closed  until  a  response  be  obtained,  we  will 
find  that  our  first  muscular  contraction  will  take  place  when  the  circuit  is  closed; 
this  is  called  the  cathodal  closure  contraction.  No  contraction  will  take  place 
when  the  circuit  is  opened;  this  can  only  be  eHcited  by  the  most  powerful 
current,  and  is  for  obvious  reasons  never  obtained  in  a  healthy  human  being. 

If  now  for  the  cathode  we  substitute  the  positive  pole,  termed  the  anode, 
we  will  get  no  response  until  we  increase  the  current  strength,  when  contrac- 
tions of  about  equal  intensity  will  occur  at  both  the  opening  and  closing  of 
the  circuit;  these  are  termed  respectively  the  anodal  opening  and  closure 
contractions. 

These  contractions  have  been  conveniently  formulated  as  follows : 

Ca  =  cathode.  C    =  contraction. 

An  =  anode.  C  =  strong  contraction. 

CI  =  closure.  C"  ==  very  strong  contraction. 

O    —  opening. 

Very  strong  current. 
Weakest  current.  q^  qj  Qrr 

Ca  CI  C.  An  CI  C. 

Strong  current.  An  O  C 

Ca  CI  C  .  Ca  O  C  (very  weak  contraction). 

[  about  equal. 
AnOC) 

Practically  the  muscles  when  directly  stimulated  respond  in  a  manner 
similar  to  that  which  ensues  when  the  supplying  nerve  is  stimulated. 

When  the  muscle  and  nerve  are  separated  from  their  trophic  centers,  the 
mode  of  reacting  to  the  current  undergoes  a  radical  change.  Further,  the 
nerve  and  muscle  each  respond  differently.  If  the  case  is  seen  immediately 
after  the  onset  of  the  disease,  which  it  rarely  is,  and  the  nerve  or  nerves  influ- 
enced by  the  diseased  cells  are  stimulated,  we  may  find  a  stronger  contraction 
of  the  respective  muscles  supplied  by  them  taking  place,  with  both  the  faradic 
and  galvanic  currents,  than  would  take  place  if  they  were  normal.  This  lasts 
for  one  or  two  days,  when  a  progressive  decrease  commences  which  continues 
in  marked  cases  untU  in  the  course  of  a  week  no  response  can  be  elicited  by 
either  form  of  current.  The  muscle  when  excited  directly  acts  similarly  with  the 
faradic  current,  but  with  the  galvanic  current  the  following  is  noticed:  Dur- 
ing the  first  week  a  slight  decrease  in  irritabiliity  will  be  noticed,  to  be  succeeded 


624  ORTHOPEDIC  SURGERY. 

by  a  marked  increase  lasting  from  three  to  six  weeks;  also,  instead  of  the  nor- 
mal short,  sharp  contraction  we  will  have  one  which  is  slow  and  long-drawn- 
out,  in  some  cases  almost  tetanic  in  character,  and  in  place  of  the  Ca  CI  C 
alone  being  excited  by  the  weakest  current  that  will  cause  a  contraction,  we  will 
find  either  the  An  CI  C  equally  prominent  or  in  severe  cases  taking  place  first; 
this  change  in  the  mode  of  contraction  is  expressed  by  formula  thus : 

An  CI  C  =  Ca  CI  C, 
or  in  severe  cases. 

An  CI  C>  Ca  CI  C. 

Ca  O  C  can  also  be  elicited  and  at  times  equals  An  O  C,  although  it  has 
never  been  observed  greater;  we  express  this  change  by  formula  as  follows: 

Ca  O  C  =  An  O  C. 

At  the  end  of  this  period  the  power  of  response  gradually  becomes  weaker; 
stronger  currents  become  necessary  to  produce  contractions.  Ca  O  C  disap- 
pears, then  An  O  C,  until  in  very  severe  cases  we  can  only  get  a  weak  An  CI  C, 
which,  if  the  case  goes  from  bad  to  worse,  finally  ceases. 

In  very  mild  cases  we  often  observe  what  is  termed  a  partial  reaction  of 
degeneration,  the  difference  being  that  when  the  nerve  is  stimulated  the  muscle 
responds  normally  or  with  only  a  slight  decrease  in  irritability.  The  muscles 
act  when  directly  stimulated  as  described  above. 

To  demonstrate  these  changes  as  detailed  above  takes  skill  and  experience, 
and  even  then  they  cannot  always  be  shown.  For  the  practical  purposes  of 
diagnosis  a  knowledge  of  the  following  facts  will  sufiice,  and  these  are  really 
the  essential  features  of  the  degenerative  reaction. 

1.  The  loss  of  the  power  of  a  muscle  to  contract  when  stimulated  by 
faradic  current,  and  the  response,  if  a  recent  case,  of  the  muscle  to  a  weaker 
galvanic  current  than  that  which  normally  causes  a  contraction. 

2.  The  existence  of  the  long  wave-like  contraction  and  An  CI  C  equaling 
or  recurring  before  Ca  CI  C. 

Some  valuable  points  in  prognosis  may  be  obtained  by  a  study  of  these 
reactions.  If  after  several  weeks  only  the  partial  degenerative  reaction  is 
present  we  can  predict  a  comparatively  speedy  recovery,  and  the  prognosis  is 
correspondingly  worse  the  farther  advanced  the  reaction  is,  and  the  longer  it 
persists  without  any  tendency  to  improvement.  This  improvement  is  manifested 
first  by  the  gradual  return  of  the  nerves  to  the  normal  reaction,  the  changes 
evolved  by  direct  stimulation  of  the  muscles  persisting  for  some  time  after  the 


INFANTILE  SPINAL  PARALYSIS.  625 

irritability  of  the  nerve  returns.  If  only  An  CI  C  is  present,  the  chances  of 
complete  restoration  are  extremely  slight  and  a  prolonged  course  of  treatment 
will  be  necessary  to  effect  any.  If  no  response  can  be  elicited,  the  case  is  practi- 
cally hopeless. 

Differential  Diagnosis. 

Infantile  paralysis  must  be  distinguished  from  cerebral  paralysis,  myelitis, 
diphtheritic  paralysis,  rachitic  pseudo-paralysis,  spastic  paraplegia,  cerebro- 
spinal meningitis,  progressive  muscular  atrophy,  pseudo-hypertrophic  paralysis, 
birth  or  pressure  palsies,  hemorrhage  into  the  cord,  multiple  neuritis,  congenital 
dislocation  of  hip,  and  hip-,  anlde-,  and  shoulder-joint  disease.  Of  these, 
it  is  most  frequently  confounded  with  other  forms  of  paralysis  (spinal  or  cerebral) 
and  progressive  muscular  atrophy  and  hip-joint  disease. 

Cerebral  Paralysis. — It  is  with  this  affection,  particularly  in  its  earlier 
stages,  that  infantile  paralysis  is  most  frequently  confounded,  and  from  which, 
when  the  latter  disease  is  hemiplegic  with  involvement  of  the  facial  nerve,  it  is 
difficult  and  almost  impossible  without  an  electric  examination  to  distinguish  it. 

In  cerebral  paralysis  the  onset  is  usually  sudden,  convulsions  frequently 
occur,  and  hemiplegia  with  facial  paralysis  results. 

In  the  disease  under  consideration,  when  hemiplegia  occurs  the  arm  usu- 
ally soon  regains  its  power  and  the  leg  remains  paralyzed,  while  the  reverse 
occurs  in  cerebral  paralysis.  In  the  latter,  also,  the  muscles  of  the  affected 
part  are  frequently  rigid;  the  tendency  to  atrophy  and  deformity  (except  post- 
hemiplegic contractures),  the  changed  electric  reactions,  and  the  lowering  of 
the  temperature  of  the  affected  part  are  all  absent.  Moreover,  the  causes  of 
cerebral  paralysis  in  children — meningitis,  cerebral  hemorrhage,  and  infec- 
tious diseases — add  their  own  appropriate  symptoms  to  the  essential  symptoms 
of  this  afi'ection. 

In  the  more  difficult  cases  the  electric  reactions  alone  will  distinguish 
between  the  two  afi'ections. 

Myelitis. — Acute  transverse  inflammation  of  the  cord  is  characterized  by 
complete  loss  of  power,  with  marked  loss  of  sensation,  with  diminished  reflex 
excitability,  and  electro-muscular  contractility  and  subsequent  atrophy  of  the 
affected  muscles.  The  loss  of  sensation,  the  tendency  of  the  affection  to  grow 
progressively  worse,  and  the  grave  character  of  the  afi'ection  would  serve  to 
distinguish  it. 

Diphtheritic    Paralysis. — Diphtheritic    paralysis    may   be    distinguished 


626  ORTHOPEDIC  SURGERY. 

by  the  previous  history,  the  association  of  paralysis  of  the  palate  and  phar}Tigeal 
muscles,  the  unchanged  electric  reactions,  and  the  absence  of  severe  atrophy. 
The  writer  has  observed  a  child  suffering  from  both  affections  at  the  same  time. 
Moreover,  the  paralysis  of  the  extremities  rarely  arises  suddenly,  and,  as  a  rule, 
they  involve  a  series  of  muscles  at  the  same  time,  improving  in  the  same  order 
as  the  individual  muscles  became  affected. 

Rachitic  Pseudo-paraplegia. — This  is  not  so  much  a  paralysis  as  an 
indisposition  to  use  what  muscular  power  is  retained  on  account  of  the  general 
tenderness.  The  loss  of  power  may  be  almost  as  great  as  in  infantile  paralysis, 
but  the  gradual  onset,  the  association  of  other  evidences  of  rickets,  especially 
local  sweating  and  nocturnal  fever,  the  absence  of  atrophy,  and  the  normal 
electric  reactions  will  serve  to  distinguish  it. 

Spastic  Paraplegia. — The  tetanoid  rigid  condition  of  the  limbs,  the 
gradual  onset,  the  exaggerated  reflexes,  the  absence  of  atrophy,  and  the 
unchanged  condition  of  faradic  irritability  would  readily  distinguish  it. 

Cerebrospinal  Meningitis. — This  may  at  the  onset  be  confounded  with 
infantile  paralysis.  The  epidemic  nature  of  the  disease,  the  opisthotonos, 
the  dorsal  pain,  hebetude,  coma,  and  conMalsions,  the  progressively  grave 
character  of  the  affection,  are  important  in  arriving  at  a  correct  diagnosis. 
Moreover,  the  paralysis,  while  frequently  hemiplegic,  is  not  permanent. 

Progressive  Muscular  Atrophy. — "Wasting  palsy"  is  of  rare  occurrence 
in  infancy  and  childhood,  and  the  gradual  onset,  corresponding  to  the  increase 
of  the  atrophy,  its  progressive  nature,  and  the  presence  of  faradic  contractility 
and  the  reflexes  as  long  as  any  muscular  fiber  remains,  will  suflice  to  distinguish 
it  in  the  earlier  stages.  Later,  during  the  stage  of  contraction  and  deformity, 
the  generalized  atrophy  of  this  disease  will  be  sufficiently  characteristic. 

Pseudo-hypertrophic  Paralysis. — Although  motor  weakness  is  the  first 
symptom  to  attract  attention  in  this  affection,  the  increased  size  of  the  muscles, 
unattended  by  any  marked  electric  changes,  is  sufficiently  characteristic;  and 
subsequently,  when  atrophy  sets  in,  its  general  distribution,  the  history,  the 
deformities  from  muscular  contractures,  the  disappearance  of  the  knee-jerk 
as  the  disease  advances,  the  entire  absence  of  the  reaction  of  degeneration, 
will  readily  distinguish  this  aft'ection  from  the  one  under  consideration. 

Pressure  or  Traumatic  Palsies. — Peripheral  paralysis  from  nerve  injury, 
as  in  birth  palsies  immediately  after  instrumental  delivery,  from  tight  bandaging 
ligature,  or  from  pressure  of  an  enlarged  gland  or  tumor  on  a  nerve,  is  usually 
limited  to  the  distribution  of  a  single  nerve  and  has  associated  loss  of  sensibility 


INFANTILE  SPINAL  PARALYSIS.  627 

and  trophic  skin  lesions.  In  all  such  the  course  of  the  great  nerves  of  the  part 
should  be  examined,  for  in  such  cases  the  electric  examination  faUs,  since  it  is 
identical. 

Hemorrhage  into  the  Cord. — Traumatic  hemorrhage  into  the  ante- 
rior cornua  is  identical  with  anterior  poliomyelitis,  cases  being  recorded  by 
Allbutt  and  Turner.  Hemorrhage  into  the  gray  substance  of  the  cord 
resembles  the  affection  under  consideration  in  its  sudden  onset,  the  subse- 
quent atrophy,  the  absence  of  reflex  action,  and  the  loss  of  electric  irritability; 
but  differs  from  it  by  the  absence  of  the  initial  pyrexia,  the  almost  instantane- 
ous occurrence  of  paralysis,  the  association  of  sensory  disturbances,  the  paralysis 
of  the  sphincters,  the  occurrence  of  bedsores,  and  other  trophic  changes. 

Multiple  Neuritis. — Of  rare  occurrence  in  childhood,  it  differs  from 
poliomyelitis  in  the  gradual  onset,  gradual  loss  of  response  to  the  faradic  cur- 
rent, the  absence  of  regression,  the  marked  hyperesthesia,  and  tenderness 
over  the  nerve-trunks.  Motion  is  painful.  It  is  important  for  the  surgeon 
to  be  familiar  with  the  uncommon  forms  of  multiple  neuritis,  such  as  Sinkler 
has  recently  recorded  from  alcohol,  coal-gas  poisoning,  metallic  poisoning, 
infectious  diseases,  etc.  Moreover,  the  association  of  the  two  affections 
should  not  be  forgotten. 

Congenital  Dislocation  of  Hip. — When  slight,  this  may  resemble  the 
disease  under  consideration,  but  may  be  distinguished  by  the  slight  atrophy, 
the  normal  electric  reactions,  the  elevation  of  the  trochanter  above  the  Roser- 
Nelaton  line,  and  the  possible  reduction  of  the  deformity  by  traction.  When 
the  hip  is  dislocated  in  infantile  paralysis,  the  difference  would  be  less,  but 
the  history  of  the  case  and  the  electric  changes  would  still  be  available  for 
diagnostic  purposes. 

Hip-joint  Disease. — When  sudden  and  associated  with  joint  pain  and 
tenderness,  severe  muscular  atrophy,  and  modified  response  to  the  faradic 
current,  the  resemblance  of  this  disease  to  anterior  poliomyelitis  is  great, 
but  the  characteristic  muscular  fixation,  the  gradual  onset,  deformed  posi- 
tion of  the  limb,  night-cries,  etc.,  would  serve  to  distinguish  it.  The  same 
symptoms,  being  those  of  osteitis  in  general,  would  serve  in  a  measure  to 
distinguish  ankle-joint  and  shoulder-joint  disease. 

Prognosis. 

With  modern  therapeutic,  mechanical,  and  operative  means,  the  pros- 
pects of  improvement  in  this  affection  are  now  exceedingly  promising.     The 


628  ORTHOPEDIC  SURGERY. 

effect  of  treatment  in  this  affection  is  most  marked.  Without  treatment  of 
any  kind,  after  the  stationary  period  the  paralysis  will  usually  improve  for 
one  or  two  months,  more  slowly  for  two  to  four  months,  after  which  it  remains 
permanently  or  improves  very  slowly.  After  a  time  atrophy,  contracture, 
relaxation,  and  malposition  lead  to  crippling  deformities,  which  locomotion 
rapidly  and  indefinitely  increases.  Treatment  faithfully  and  persistently 
continued  is  frequently  rewarded  by  the  return  of  power  and  usefulness  in 
an  atrophied  and  helpless  limb,  while  apparatus  and  surgical  skill  will  not 
only  correct  deformities,  but  will  hasten  and  increase  the  improvement. 

During  the  initial  stage  the  danger  to  life  is  exceedingly  slight,  though 
in  very  rare  cases  the  patient  may  succumb  at  the  onset  from  respiratory 
failure. 

Cerebral  complications  add  to  the  gravity  of  the  prognosis.  An  attack 
of  this  affection  may  during  convalescence  render  the  patient  less  resistant 
to  other  and  more  fatal  diseases.  There  is  no  evidence  to  prove  that  mod- 
erate deformity  from  this  disease  shortens  the  tenure  of  life.  After  the  par- 
alysis has  become  stationary,  in  about  a  week  or  ten  days,  it  is  not  likely  to 
increase,  and  the  possible  improvement  or  recovery  of  the  affected  muscles 
may  be  estimated  by  an  electric  examination.  Perfect  recovery  is  rare,  but 
improvement  may  be  looked  for  even  in  the  severest  cases.  The  muscles 
which  do  not  respond  to  the  faradic  current  will  probably  remain  perma- 
nently paralyzed.  After  a  few  days  the  muscles  which  at  first  gave  no 
response  may  feebly  respond,  and  these  may  be  expected  to  recover  partially 
or  completely.  When  no  loss  of  faradic  contractility  is  observed  after  the 
paralysis  has  become  permanent,  recovery  may  be  predicted  in  a  few  weeks 
or  months.  When  the  faradic  contractility  gradually  fails,  wasting  and  par- 
alysis for  an  extended  period  may  be  predicted.  When  complete  paralysis 
and  marked  atrophy  are  observed,  within  two  or  three  months  the  perma- 
nency of  the  paralysis  may  be  predicted.  As  long  as  the  feeblest  response 
remains  to  the  faradic  current  improvement  may  be  predicted,  but  if  the 
"reaction  of  degeneration"  is  present  the  paralysis  may  be  considered  abso- 
lutely permanent.  Even  in  the  severest  cases  great  improvement  may  be 
obtained  by  mechanical  and  operative  treatment,  the  possibilities  being  only 
limited  by  the  extent  of  the  paralysis  and  amount  of  atrophy  of  the  upper 
extremities.  Only  cases  which  are  so  extensively  paralyzed  as  to  be  unable, 
with  apparatus,  to  use  a  wheel-crutch,  are  not  amenable  to  treatment;  and 
frequently,   under   modern   methods,    children   apparently   doomed   to    spend 


INFANTILE  SPINAL  PARALYSIS.  629 

the  rest  of  their  Hfe  as  helpless  cripples  upon  the  floor  are  restored  to  health 
and  usefulness. 

Prophylaxis. 

A  word  of  warning  may  here  be  given,  since  certain  simple  prophylactic 
measures  may  prevent  the  advent  of  this  disease  with  its  terrible  crippling 
deformities.  Since  its  principal  exciting  cause  is  the  sudden  chilling  of  the 
overheated  surface  of  the  body  during  a  season  of  the  year  when  the  greatest 
mean  relative  humidity  of  the  atmosphere  is  accompanied  with  great  heat, 
due  precaution  on  the  part  of  nurses  and  parents  may  prevent  its  occurrence. 
To  this  end  children  should  not  be  allowed  to  become  greatly  overheated 
nor  be  exposed  to  the  sun  for  long  periods,  and  should  not  be  allowed  to  lie 
on  damp  grass  nor  sit  vipon  damp  stones  when  in  an  overheated  condition. 
The  body,  especially  in  delicate  children,  should  be  well,  but  lightly,  cov- 
ered, preferably  with  light  natural  wool  or  hygienic  garments,  and  under  no 
circumstances  should  a  child  be  allowed  to  take  a  cold  or  tepid  bath  when 
greatly  overheated. 

Treatment. 

The  character  of  the  treatment  will  depend  upon  the  stage  or  period 
during  which  the  disease  is  seen. 

Medical  Treatment. — The  Stage  of  Onset. — During  the  first  stage, 
before  the  development  of  paralysis,  the  indications  are  to  reduce  the  tem- 
perature, to  remove  the  exciting  cause,  and  to  relieve  the  urgent  symptoms 
present.  Active  measures  at  this  time  may  limit  the  amount  of  destruction 
in  the  cord.  A  brisk  purge,  preferably  of  calomel,  rhubarb,  or  magnesia, 
should  be  administered,  and  a  febrifuge  mixture  be  prescribed.  If  worms 
in  the  intestines  are  suspected  as  the  cause,  santonin  should  be  added  to  the 
calomel.  A  general  hot  bath  should  be  administered,  and  the  child  placed 
upon  the  side  or  face  to  limit  stasis  of  blood  in  the  cord;  mustard  plasters, 
tincture  of  iodin,  or  dry  cups,  should  be  applied  to  the  spine,  especially 
over  the  cervical  and  lumbar  enlargements. 

For  dental  irritation  the  gums  should  be  lanced  at  once.  If  genital  irri- 
tation exist  and  phimosis  be  suspected  as  the  cause,  circumcision  will  be 
mdicated  as  soon  as  the  more  acute  symptoms  have  subsided,  and  may  be 
followed  by  the  speedy  amelioration  of  the  paralysis. 

If  the  disease  be  ushered  in  with  a  convulsion,  cold  may  be  applied  to 


630  ORTHOPEDIC  SURGERY. 

the  head.  Ergot  is  strongly  recommended,  and  ten  drops  of  the  fluid  extract 
may  be  administered  to  infants  of  six  months  and  one-half  dram  to  children 
between  one  and  two  years.  Ergotin  may  be  given  by  suppositories  when 
the  patient  cannot  swallow.  Belladonna,  mercurial  inunctions,  hydrargyrum 
cum  creta,  and  iodid  or  bromid  of  potassium  have  been  recommended  in 
the  acute  stage.  Rest  and  quiet,  with  a  sterilized- milk  diet,  should  be  insisted 
upon,  and  a  moderately  cool  temperature  should  be,  if  possible,  secured. 
Strychnin  has  been  recommended  both  internally  and  by  h3^odermatic  injec- 
tion, but  its  value  is  greatest  in  the  paralytic  stage  of  the  disease  when  no 
signs  of  the  initial  irritation  remain. 

Stage  of  Paralysis. — During  the  acute  and  the  early  part  of  the  station- 
ary period  the  paralyzed  parts  are  to  be  protected  from  strain  and  pressure, 
and  measures  are  to  be  adopted  which  will  diminish  the  amount  of  the 
deformity,  hasten  the  regression,  and  secure,  if  possible,  the  maximum 
improvement. 

The  limbs  should  be  enveloped  in  sheet  lint  or  lintine  and  neatly  ban- 
daged; should  be  placed  upon  pUlows  and  supported  by  sandbags,  pillows, 
etc.,  in  such  a  manner  as  to  avoid  any  undue  tension  and  stretching  upon 
the  paralyzed  muscles  or  relaxed  ligaments.  The  weight  of  the  bedclothes 
must  be  taken  off  the  toes  by  a  bed-hoop  or  other  device.  If  the  paralysis 
be  more  extensive,  a  canvas-covered  frame  or  a  wire  cuirass  may  be  employed 
to  secure  perfect  rest  to  the  palsied  parts,  and  enables  the  child  to  be  carried 
about.  The  arm  when  paralyzed  may  be  secured  in  a  sling  or  preferably 
a  well-applied  roller  bandage,  pressure  being  carefully  avoided.  It  is  essen- 
tial that  the  limb  should  he  kept  warm  at  all  times.  The  limb  should  be 
constantly  incased  in  woolen,  and  in  winter  be  additionally  protected  by 
chamois  or  buckskin.  Dry  heat  may  be  applied  several  times  a  day  by  sit- 
ting before  the  fire  with  the  paralyzed  limb  placed  through  a  hole  in  a  sheet 
of  heavy  cardboard  or  wood.  Friction,  rubbing,  or  massage  is  very  useful, 
and  is  best  applied  by  the  bare  hand,  but  sweet  oil  or  vaselin  may  be  used 
if  the  dry  rubbing  produce  irritation. 

Massage  is  best  given  by  persons  skilled  in  its  employment,  but  where 
the  expense  is  too  great  the  rubbing  may  be  substituted.  Its  use,  at  first, 
must  be  limited,  and  ten  or  fifteen  minutes  will  be  sufficiently  long  if  only 
one  extremity  is  affected,  and  the  time  may  be  gradually  extended  to  twenty 
or  thirty  minutes.  The  massage  is  best  applied  at  night  after  the  limb  has 
been  thoroughly  warmed,  and  consists  of:    First,  firm  stroking,  applied  over 


INFANTILE  SPINAL  PARALYSIS.  631 

the  entire  limb  from  the  foot  to  the  hip;  second,  friction  applied  from  below 
upward,  and  followed  by  stroking;  third,  kneading,  the  tissues  being  care- 
fully separated;  and,  fourth,  percussion  over  the  muscular  parts  of  the 
entire  limb. 

For  the  details  of  these  movements  the  reader  is  referred  to  Part  I. 

Finally,  the  foot,  leg,  and  thigh  should  be  rotated  gently  and  firmly,  and 
the  joints  should  be  carried  through  their  normal  movements  several  times. 

A  period  of  rest  must  follow  these  manipulations  at  all  times,  so  that 
they  are  preferably  performed  at  bedtime. 

Exercise  of  the  paralyzed  limb,  preferably  on  the  principle  of  the  Swedish 
movement  cure,  will  form  a  valuable  adjunct  to  the  rubbing  or  massage. 

Muscle  and  brain  are  developed  by  reciprocal  action  and  every  move- 
ment of  a  composite  nature  develops  equally  the  gray  centers  of  the  brain 
and  cord.  Active  muscular  exercise,  however  obtained,  enables  the  weak- 
ened muscles  to  regain  their  power  and  daily  places  them  at  a  greater  advan- 
tage. For  the  general  effect  of  exercise  the  reader  may  be  referred  to  one  of 
the  writer's  former  papers  upon  "Physical  Development  in  Children"  (Keat- 
ing's  "Cyclop.  Dis.  of  Children,"  vol.  iv). 

In  the  treatment  of  this  affection  every  movement  of  the  paralyzed  part 
which  can  be  accomplished,  provided  the  muscles  are  not  overtaxed,  may 
be  employed.  No  exact  series  of  exercises  can  be  given,  and  the  exercises 
must  be  varied  to  suit  the  individual  case.  To  the  same  end  apparatus 
should  be  early  employed,  to  enable  the  child  to  walk  as  soon  as  possible, 
and  so  increase  the  amount  of  exercise. 

Electricity  is  the  most  important  remedy  at  our  command  to  restore 
power  to  the  paralyzed  muscles.  Its  use  should  always  be  deferred  until  all 
symptoms  of  inflammation  have  subsided,  as  seen  by  the  absence  of  fever 
and  hyperesthesia.  The  author  allows  four  to  six  weeks  to  elapse  before 
beginning  the  electric  treatment.  For  two  or  three  weeks  only  the  mildest 
currents  may  be  employed  and  these  only  for  a  limited  period.  The  rule  in  the 
administration  of  electricity  is  to  use  the  current  which  will  give  the  greatest 
amount  of  contraction  with  the  least  amount  of  current  and  the  smallest 
amount  of  pain.  The  slowly  interrupted  faradic  current  is  to  be  preferred, 
and  each  muscle  may  be  made  to  contract  three  or  four  times  and  the  treat- 
ment should  be  applied  daily.  Galvanism  is  to  be  substituted  when  the  mus- 
cles fail  to  respond  to  the  faradic  current.  The  good  effect  of  the  electricity 
is  observed  in  the  increasing  size  and  power  of  the  paralyzed  part,  and  the 


632  ORTHOPEDIC  SURGERY. 

improved  circulation  and  appearance  of  the  skin.  Electricity  is  also  useful, 
after  the  parts  have  reached  their  maximum  development,  to  maintain  the 
nutrition  of  the  tissues.  Strychnin  is  a  valuable  adjunct  to  electricity  in  this 
stage.  In  the  later  stages  massage  and  active  muscular  exercise  will  be  of 
more  importance  than  electricity. 

Mechanical  Treatment.- — The  principles  involved  in  the  mechanical 
treatment  of  infantile  paralysis  are:  first,  the  support  and  protection  of  the 
limb  in  a  manner  which  w'Al  render  it  most  serviceable  for  progression,  and 
at  the  same  time  exercise  as  much  as  possible  the  weakened  muscles;  and, 
second,  the  prevention  and  correction  of  deformities.  The  lightest  form  of 
apparatus  which  \\\\\  accomplish  this  should  always  be  selected,  and  parti- 
cular attention  must  be  taken  to  have  the  bands  thoroughly  padded,  and  fric- 
tion must  be  avoided,  since  the  circulation  of  the  part  is  poor.  Rubber  elastic 
bands  are  of  ser^^ce  in  some  forms  of  apparatus  to  assist  weakened  and 
partially  recovered  muscles,  but  rigid  appliances  with  locks  and  catches  at 
the  joints  are  to  be  preferred,  the  main  use  of  braces  being  the  support  of 
the  joints. 

Mechanical  appliances  will  be  indicated  whenever  the  limbs  cannot  sup- 
port the  weight  of  the  body,  and  where  in  locomotion  the  weight  of  the  body 
produces  distortion  and  deformity  of  the  limbs.  No  special  form  of  appa- 
ratus can  be  given  to  meet  all  cases,  and  the  changes  and  alterations  required 
will  tax  to  the  utmost  the  ingenuity  of  the  surgeon  and  the  skill  of  the  instru- 
ment-maker. 

The  conditions  requiring  mechanical  appliances  may  be  considered  under 
four  divisions 

1.  Paralysis  of  the  lower  extremity. 

2.  Paralysis  of  the  trunk  and  lower  extremity. 

3.  Paralysis  of  the  trunk. 

4.  Paralysis  of  the  upper  extremity. 

Paralysis  of  the  lower  extremity.  The  application  of  mechanical 
appliances  for  the  relief  of  paralysis  of  the  lower  extremity  will  include 
appliances  for  paralysis  of  the  leg  with  associated  varus,  valgus,  and  calca- 
neus; appliances  for  paralysis  of  the  thigh  muscles;  and  appliances  for  com- 
plete paralysis  of  the  lower  extremitv. 

When  simple  calcaneus  results  from  paralysis  of  the  anterior  muscles 
of  the  leg,  the  foot  may  be  prevented  from  fully  extending  by  attaching  lateral 
steel  uprights  to  the  ordinary  shoe,  and   the  addition  of  a  right-angle  stop- 


INFANTILE  SPINAL  PARALYSIS. 


633 


joint  opposite  the  ankle-joint.  A  single  upright  of  this  kind  upon  the  outer 
side  of  the  leg  extending  to  a  little  below  the  knee  may  be  used,  but  double 
uprights  are  preferable. 

The  same  result  may  be  accomplished  by  means  of  a  light,  firm  spring 
attached  to  the  ankle-joint  of  the  brace,  which  automatically  elevates  the 
toes,  and  which  the  weight  of  the  body  in  stepping  readily  overcomes.  The 
same  result  may  be  obtained  from  elastic  straps  attached  to  the  outer  and 
inner  sides  of  the  toes  of  the  shoe,  crossed  in  front  of  the  ankle,  and  buckled 
or  fastened  to  the  leg- band  above.  In  all  these  appliances  in  which  an  ordi- 
nary shoe  is  used,  a  steel  plate  must  be  inserted  between  the  leather  of  the 
sole  during  the  making  of  the  shoe,  or  an  inside  steel  plate 
must  be  attached  to  the  shoe  when  the  brace  is  attached. 

When  varus  coexists  from  the  foot  rolling  inward 
from  the  weakness  of  the  tendons  about  the  ankle-joint, 
and  the  relaxation  of  the  ligaments,  a  pad  should  be 
fastened  to  the  outer  ankle-joint  of  the  apparatus,  and 
a  leather  T-strap  should  be  added  to  the  outer  side  of 
the  shoe,  and  buckled  over  the  inner  upright. 

If,  as  is  often  the  case,  valgus  is  associated,  this  pad 
and  T-strap  should  be  attached  to  the  inner  side,  and  in 
addition  a  steel  plantar  spring,  described  under  acquired 
club-foot,  will  afford  additional  support,  and  tend  to  invert 
the  foot  to  its  normal  position.  In  many  cases  the  T-strap 
may  be  dispensed  with,  and  a  strap  of  webbing  may  be 
attached  to  the  outer  upright  just  above  the  external 
malleolus. 

When  the  thigh  muscles  are  paralyzed  the  limb  drops 
forward,  and  is  unable  to  sustain  the  weight  of  the  body, 
be  thrown  backward  from  relaxation  of  the  posterior  ligaments,  the  limb  furnishes 
some  support,  but  "back-knee"  results.  For  these  conditions  it  is  necessary  to 
support  the  knee  in  a  fully  extended  position.  This  is  readily  accomplished 
by  carrying  an  outer  and  inner  steel  bar  from  the  shank  of  the  shoe  to  the 
upper  part  of  the  thigh,  to  be  attached  to  a  posterior  steel  band,  and  at  the 
knee  a  broad  leather  band  maintains  the  knee  in  position. 

This  is  the  principle  upon  which  all  paralysis  leg  braces  are  constructed, 
but  for  convenience  in  sitting  they  should  be  furnished  with  a  lock  or  catch 
at  the  knee.     For  this  purpose  numerous  catches  are  in  use,  of  which  the  best 


Fig.  452. — Ankle  Support 
roR  Talipes  Valgus. 


If,  however,  the  limb 


634 


ORTHOPEDIC  SURGERY. 


are  the  drop-catch  and  the  Congden.  The  drop-catch  consists  of  a  simple 
ring  "which  falls  when  the  limb  is  extended,  and  may  be  raised  with  ease  to 
permit  flexion.  The  Congden  consists  of  semicircular  pieces  of  steel  attached 
to  the  knee-joints  on  either  side,  into  which  the  ends  of  a  steel  bow  play  in 
such  a  manner  as  to  lock  automatically  when  the  limb  is  extended,  but  which, 
upon  being  slightly  elevated,  permits  the  knee  to  flex. 


Fic.  453. — Infantile  Paralysi.s  Brace. 


Fig.  454. — Same,  with  Extension  Shoe. 


To  prevent  hyperextension  of  the  knee  the  knee-joints  of  the  apparatus 
should  have  a  stop-joint. 

If  the  loss  of  power  be  not  complete,  the  muscles  may  be  assisted  by 
elastic  bands  so  attached  to  projecting  bars  as  to  supplement  the  palsied  part, 
and  the  stop-joint  or  catch-joint  is  omitted. 


INFANTILE  SPINAL  PARALYSIS. 


635 


Where  contraction  of  the  hamstring  tendons  produces  deformity  of  the 
knee,  this  may  be  overcome  by  tenotomy. 

A  very  useful  brace  for  the  correction  of  flexion  of  the  knee  from  paraly- 
sis of  the  quadriceps  extensor  con- 
sists of  an  ordinary  paralysis  brace 
extending  from  the  sole  of  the  foot 
to  the  upper  part  of  the  thigh,  to 
which  at  the  knee-joints  are  at- 
tached semicircular  plates  at- 
tached to  the  lower  upright,  and 
perforated  near  the  border  so  as  to 
be  altered  by  a  screw  to  any  angle. 
Pressure  is  applied  by  means  of  a 
leather  loiee-cap,  provided  with 
four  straps  closely  perforated  to  fit 
the  pins  upon  the  lateral  uprights. 
Instead  of  the  semicircular  pieces, 
a  worm-screw  and  ratchet  may  be 
attached,  and  with  a  key  the  splint 
can  be  set  at  any  angle. 

Either  of  these  braces  should 
fit  accurately,  and  this  may  be 
secured  by  broad  leather  bands 
above  and  below  the  knee,  at- 
tached laterally  to  the  brace  and 
laced  in  front. 

In  many  of  these  cases  the 
affected  limb  will  be  found  shorter 
than  the  sound  one,  and  in  apply- 
ing the  apparatus  the  length  of 
the  limbs  must  be  equalized  by 
applying  an  insole  or  a  high  cork 
patten  to  the  shoe  of  the  short  side. 

Paralysis  of  the  lower  extremity  and  trunk.  In  these  cases,  which 
without  operation  and  apparatus  are  practically  helpless,  the  entire  body 
from  the  feet  to  the  axillas  must  be  made  rigid,  to  support  the  weight  while 
the  body  is  swung  forward  upon  crutches. 


Fig.  455. — Paralysis  Bkace  with  Rubbkr  Muscles. 


636 


ORTHOPEDIC  SURGERY. 


The  body  may  be  incased  in  a  leather  jacket,  or  a  steel  framework  may 
be  made  to  encircle  the  trunk,  and  to  this  the  leg  appliances  can  be  con- 
nected. To  enable  the  patient  to  sit,  locking  and  unlocking  joints  at  the 
hips  and  knees  are  essential.  If  possible,  crutches  should  be  employed;  but 
if  these  cannot  be  held  securely,  a  steel-framed  walking  apparatus,  a  Darrach 
wheeled  crutch,  trolley  suspension,  or  the  wheeled  crutch  wUl  be  found  useful. 

These  are  simply  light  frames  with  wheels,  the  top  of  the  framework 
being  padded  to  fit  under  the  axillas,  and  with  straps  or  a  padded  piece  of 
metal  for  the  hands  to  hold.     By  such  apparatus  the  unaffected  muscles  are 


Fig.  456. — Paralysis  Brace  for  Infantile  Par- 
alysis. 


Fig.  457. — Paralysis  Brace. 


exercised,  and  the  weakened  ones  are  also  brought  into  use.  The  construction 
and  use  of  these  apparatus  are  well  shown  in  the  accompanying  illustrations 
(Figs.  458  and  459)  and  need  not  here  be  described. 

Paralysis  of  the  trunk.  Paralysis  of  the  trunk  muscles  seldom  occurs 
except  in  connection  with  extensive  paralysis  of  one  or  both  lower  extremities. 

Paralysis  of  the  muscles  of  the  back,  when  unilateral,  gives  rise  to  lateral 
curvature,  and  for  its  relief  the  mechanical  appliance  considered  under  the 
treatment  of  that  affection  can  be  employed.  Bilateral  paralysis  renders  the 
spine  unable  to  maintain  an  erect  position,  and  demands  for  its  relief  the  use 


INFANTILE  SPINAL  PARALYSIS. 


637 


of  corsets  of  leather,  wood,  wire,  etc.,  as  employed  in  the  treatment  of  Pott's 
disease  of  the  spine.  In  these  cases  crutches,  or  wheeled  crutches,  or  a  couch, 
will  be  required  for  locomotive  purposes. 

Paralysis  of  the  abdominal  muscles  gives  rise  to  a  marked  lordosis,  with 
a  protuberant  abdomen.  In  mild  cases  abdominal  corsets  or  supports  will 
relieve  the  deformity,  and  in  severer  cases  a  well-fitting  leather  jacket  will 
be  serviceable. 

Paralysis  of  the  upper  extremity.     The  mechanical  appliances' used 


Fig.  458. — Wheel  Chair  for  Infantile  Paralysis  (Willard). 


Fig.  459. — Trolley  Suspension  for 
Infantile  Paralysis  (Willard). 


in  paralysis  of  the  deltoid  to  prevent  further  relaxation  of  the  acromiohumeral 
ligaments  consist  of  a  well-padded  leather  breast-ring  encircling  the  base 
of  the  neck,  with  a  leather  band  for  the  forearm  attached  to  it  by  straps. 
More  complicated  apparatus  may  be  employed,  consisting  of  a  well-fitting 
shoulder-piece  and  elevating  springs  attached  to  an  arm-band  encircling  the 
part.     In  some  cases  a  simple  handkerchief  sling  will  answer  every  purpose. 

In  cases  of  wrist-drop  elastic  bands  may  be  substituted  for  the  paralyzed 
extensor  muscles.  If  the  flexor  muscles  become  permanently  contracted, 
tenotomy  or  transplantation  of  tendons  must  be  performed. 


638 


ORTHOPEDIC  SURGERY. 


Operative  Treatment. — ^This  is  demanded  when  mechanical  methods 
are  inefficient  or  undesirable,  and  affords  the  most  speedy  and  efficient  result 
in  the  severest  cases. 

It  includes  (i)  tenotomy,  (2)  tendon-shortening,  (3)  transplantation  of 
muscles  and  tendons,  (4)  -  aponeurotomy,  (5)  myotomy,  (6)  neural  anasto- 
mosis, (7)  forcible  straightening,  (8)  excision,  (9)  osteotomy,  (10)  arthrodesis. 


Fig    46c — Spastic  Paraplegia  before  Operation. 


Fig.  461. — Same,  after  Operation. 


and  (11)  amputation.     Several  of  these  procedures  may  be  combined  in  one 
operation. 

The  advantage  of  operative  treatment  is  that  it  places  the  parts  in  con- 
dition for  subsequent  orthopedic  treatment.  Great  vigilance  should  be  exer- 
cised in  performing  operations  upon  cases  of  infantile  palsy  because  of  their 
low  vitality  and   poor   respiratory  action.      Especially   should    the    urine    be 


INFANTILE  SPINAL  PARALYSIS. 


639 


examined  carefully  for  acetone,  since  Bracket,  Stone,  and  Low  have  recorded 
fatal  cases  attended  by  acetonuria.  Acetonuria,  if  present  before  operation, 
in  my  opinion  is  regarded  as  a  contraindication  to  operation.  If  it  appears 
after  operation,  it  is  always  to  be  regarded  as  a  grave  complication. 


Fig.  462. — Lengthening  of  the  Tendo  Achillis 
BY  Dividing  and  Slipping  the  Two  Halves 
OVER  Each  Othek  (Berger  and  Eanzet). 


Fig.  463. — Suture  of  the  Two  Hal\'es  after 
THE  Operation  of  Lengthening  (Berger  and 
Banzet). 


I.  Tenotomy.  This  may  be  performed  subcutaneously  or  as  an  open 
incision,  the  latter  being  the  only  safe  method  where  the  deep  structures  about 
the  hip  or  knee  have  to  be  divided.  In  either  case  the.technic  is  the  same 
as  already  given,  and  strict  asepsis  must  be  observed. 

Immediate  rectification   should  be  accomplished,   but   over-correction  is 


640 


ORTHOPEDIC  SURGERY. 


not  necessary  here  as  in  congenital  deformities.  Contraction  of  the  hip  will 
require  division  of  the  sartorius,  long  head  of  the  rectus  femoris,  and  tensor 
vaginae  femoris,   and  by  carefully  avoiding  the  femoral  artery  and  anterior 


Fig.  464. — Tkaxsplantation  of  the  Fascia  of  the 
Extensor  of  the  Great  Toe  to  the  Tendon  of 
THE  Anterior  Leg,  of  the  Fascia  of  the  Short 
Peroneal  Lateral  to  the  Common  Extensors  of 
the  Toes. 

E.P,  Fascia  of  tendon  of  e.xtensor  proprius  hallucis;  J.A, 
anterior  aspect  of  leg;  C.P,  peroneus  brevis;  E.C, 
extensor  communis  digitorum. 


Fig.  465. — Tr.ansplantation  of  a  Tendinous 
Fascia  of  the  Extensor  of  the  Great 
Toe  to  the  Tendon  of  the  Common  Ex- 
tensor. 

E.C,  E.xtensor  communis  digitorum;  E.P,  1, 
extensor  proprius  hallucis;  E.P,  2,  sound 
portion  of  same;  /.yl, anterior  aspect  of  leg. 


crural  nerve  these  may  often  be  accomplished  subcutaneously.  If  the  psoas, 
the  capsule  of  the  joint,  and  the  external  or  internal  rotators  require  division,  a 
longitudinal  open  incision  of  considerable  length  will  be  necessary.       The 


INFANTILE  SPINAL  PARALYSIS. 


641 


adductors  may  be  divided  subcutaneously,  when  it  is  always  advisable  to  have 
the  skin  puncture  as  far  removed  from  the  genitals  as  possible.  This  is 
accomplished  by  pulling  the  skin  inward  when  the  puncture-  is  made.  Sub- 
cutaneous section  of  the  psoas,  although  it  has  been  successfully  accomplished, 
is  not  a  safe  operation,  and  is  therefore  best  performed  by  open  section.  In- 
jury necessitating  ligation  of  the  femoral  artery  has  resulted  from  an  attempt 
by  Phelps  to  divide  the  psoas  subcutaneously. 

Contraction  of  the  knee   in   severe  cases  will  require  tenotomy  of  the 


Fig.  466. — Transplantation  of  the  Fascia  of  thk  Long 
Flexor  to  the  Tendo  Achiliis  (Bcrger  and  Banzet). 

T-A,  Tendo  Achiliis;  L.Fl,  long  flexor;  L.Fl,  i,  sound  portion 
of  tendon  of  long  flexor;  2,  same  divided;  3,  fascia  of 
tendo  Achiliis. 


Fig.  467. — Transplantation  op  the  Peeoneus  Longus 
to  the  Tendo  Achillis. 

L.P,  I,  Sound  portion  of  peroneus  longus;  L.P,  2,  fascia 
of  tendon  of  peroneus  longus;  T.A,  tendo  Achillis;  3, 
fascia  of  tendo  Achillis;  C.P,  tendon  of  peroneus  brevis. 


hamstring  tendons,  and  in  some  instances  this  had  best  be  accomplished  by 
the  open  method,  since  the  parts  are  often  greatly  distorted  and  it  is  difficult 
to  distinguish  the  structures.  In  this  manner  the  dense  bands  in  the  region 
of  the  popliteal  space  may  more  safely  be  divided. 

2.  Tendon  shortening.  For  severe  calcaneus,  resection  or  shortening 
of  the  tendo  Achillis  is  desirable,  and  the  methods  for  its  performance  are 
fully  described  under  paralytic  club-foot.  To  avoid  removal  of  any  piece 
of  tendon  the  method  of  Walsham  and  Willett  is  to  be  preferred.     Where 


642 


ORTHOPEDIC  SURGERY. 


the  peroneals  are  intact,  an  excellent  surgical  procedure  is  to  divide  the  tendo 
Achillis  and  sew  the  peronei  tendons  to  it,  so  that  the  contraction  of  the  pero- 
neal tendons  would  elevate  the  heel. 

3.  Transplantation  of  muscles  and  tendons.  Additional  muscular 
power  may  be  gained  by  transplanting  a  portion  of  the  flexor  proprius  hal- 
lucis,  which  frequently  escapes  paralysis,  as  suggested  by  Berger  and  Banzet. 


Fig.  46S. — Tendon  Transplantation  fok   Infan- 
tile Paealysis  (Willard). 


Fig.  469. — Same,  Posterior  View. 


In  paralysis  of  the  quadriceps  extensor,  transplantation  of  the  biceps 
and  semitendinosus  tendons  to  the  rectus  femoris  tendon  has  been  found  to 
be  efficient.  Or  if  not  paralyzed,  the  tendon  of  the  sartorius  muscle  may  be 
similarly  transplanted. 

Wliere  a  condition  of  valgus  is  present,  the  extensor  proprius  hallucis 
can  be  attached  to  the  tibialis  anticus,  or  the  peroneus  tertius  and  part  of  the 
extensor  communis  digitorum  may  be  attached  to  the  tibialis  anticus. 


Fig.  470. — Poliomyelitis  in  Woman  of  Tuii'Ty,  with 
Right-angled  Ankylosis  oe  Both  Hips  (Lange). 


Fig.  471  — Saiie,  Lateral  View  (Lange). 


Fig.  472.— Poliomyelitis  in  a  Girl  of  Twelve,  before  Fig.  473.— Same,  after  Operation  (Lange). 

Operation  (Lange). 


INFANTILE  SPINAL  PARALYSIS.  645 

It  must  be  remembered  that  in  performing  all  tendon  transplantations, 
the  success  of  the  operation  largely  depends  upon  maintaining  the  proper 
amount  of  tension  in  the  transplanted  tendon. 

4.  Aponeurotomy  of  all  contracted  muscles  will  be  demanded  wherever 
they  interfere  with  the  correction  of  the  deformity. 

5.  Myotomy.  Resection  of  the  quadriceps  has  been  performed  by  Keetley 
for  paralysis  and  stretching  with  contraction  of  the  knee. 

After  operation  for  contraction  about  the  knee,  horizontal  bed  exten- 
sion with  constant  pressure  over  the  knee  is  beneficial.  Tenotomy  about  the 
foot  for  deformity  is  fully  described  under  paralytic  club-foot.  The  teno- 
tomies are  best  performed  subcutaneously,  except  that  of  the  posterior  tibial, 
which  is  best  divided  by  the  open  method.  In  talipes  equino-varus  the  tibi- 
alis anticus,  posticus,  plantar  fascia  and  ligaments  will  all  require  division. 
In  talipes  valgus  the  peroneals  require  division,  an  operation  the  writer 
strongly  advocates  and  one  to  which  sufficient  attention  has  not  been  given 
by  surgeons.     Forcible  rectification  will  also  be  serviceable  after  tenotomy. 

6.  Neural  anastomosis.  The  operation  of  transplantation  of  nerves 
is  especially  adapted  to  selected  cases  of  infantile  palsy.  The  theory  upon 
which  this  operation  is  founded  depends  upon  the  absence  of  paralysis  in 
other  centers  the  peripheral  nerves  from  which  are  sufficiently  near  the  par- 
alyzed nerves  to  admit  of  the  use  of  the  sound  centers  through  the  anasto- 
mosis of  the  paralyzed  nerves  to  those  which  are  normal.  The  technic  has 
already  been  described  in  Part  I. 

Anastomosis  of  branches  of  the  anterior  tibial  with  the  musculocutaneous, 
and  of  the  external  and  internal  popliteal  nerves,  has  been  successfully  per- 
formed by  the  writer,  and  Spitzy  has  proposed  an  anastomosis  of  the  obtu- 
rator with  the  longer  saphenous  branch  of  the  anterior  crural  nerve. 

The  future  possibilities  of  this  operation  are  as  yet  undetermined. 

7.  Forcible  straightening.  An  extreme  amount  of  force  is  sometimes 
required,  and  may  be  employed  with  safety  if  only  the  surgeon's  hands  or  sand- 
bags be  used.  Fracture  is  to  be  avoided;  but  if  it  occurs  it  will  heal  readUy 
and  will  not  complicate  the  case. 

8.  Excision  of  the  knee-joint  or  ankle-joint  may  be  required  on  account 
of  extreme  deformity  or  in  order  to  secure  a  stiff  joint.  In  the  poorer  classes 
resection  in  preference  to  the  application  of  apparatus  may  be  seriously 
considered. 


646  ORTHOPEDIC  SURGERY. 

9.  Osteotomy  and  osteoclasis  have  been  found  to  be  satisfactory  in  in- 
knee  and  out-knee. 

10.  Arthrodesis.  Arthrodesis  in  order  to  secure  a  stiff  joint  is  of 
greatest  value  in  the  ankle-joint,  especially  if  associated  with  transplanta- 
tion of  tendons.  The  technic  of  the  operation  has  already  been  described 
in  Part  I,  and  its  application  in  paralytic  calcaneus  will  be  described  under 
paralytic  club-foot. 

In  severe  cases  of  deformity  about  the  ankle  and  foot,  if  resection  of  the 
tarsal  bones  becomes  necessary,  the  removal  of  the  astragalus  is  to  be  pre- 
ferred to  tarsectomy,  and  both  are  to  be  considered  as  last  resorts,  for  in  most 
cases  powerful  force  will  accomplish  all  that  can  be  gained  by  operative 
methods. 

11.  Amputation  will,  in  exceptional  instances,  become  necessary. 
Treatment    after    Operation. — The    after-treatment    will    include    bed 

extension  and  the  thorough  use  of  massage  and  electricity  for  a  long  period. 
After  thorough  correction  by  operative  means  mechanical  appliances  are 
often  necessary.  These  are  the  same  as  have  been  fuUy  described  under 
the  mechanical  treatment  of  paralysis  of  the  lower  extremity  and  trunk. 
With  these  measures  the  most  satisfactorj'  results  can  be  obtaiaed,  and  a  num- 
ber of  successful  cases  have  been  recorded,  and  the  writer's  experience  has 
demonstrated  the  fact  that  there  are  very  few  cripples  suft'ering  from  infantile 
spinal  paralysis  that  cannot  be  helped  by  some  such  thorough  surgical  and 
mechanical  treatment  as  that  just  described. 


CHAPTER  XIX. 
INFANTILE   CEREBRAL   PALSIES. 

The  cerebral  palsies  in  children  consist  of  certain  spastic  palsies  due  to 
cerebral  defect,  with  atrophy,  usually  slight,  of  the  affected  muscles,  and  without 
marked  changes  in  electric  reaction. 

Although  mentioned  by  Reil  in  1812,  the  first  accurate  descriptions  were 
given  by  Henoch  in  1842,  and  by  Little  in  1853.  Since  this  time  numerous 
rtionographs  have  appeared  and  many  valuable  papers  have  been  contributed. 

Under  the  generic  term  cerebral  palsies — the  German  Cerebmle  Kinder- 
Idhmung — are  included  a  large  group  of  motor  palsies,  the  result  of  a  destruc- 
tive lesion  of  the  centers  of  the  upper  or  corticospinal  portion  of  the  motor  path, 
sharply  defined  in  their  clinical  features  from  the  palsy — the  common  infantile 
paralysis — due  to  a  lesion  of  the  lower  or  spino-miiscular  portion  of  the  motor 
tract.  The  relative  frequency  of  these  two  groups  is  estimated  to  be  about  i 
to  1.56. 

The  cerebral  palsies  are  classified,  according  as  the  distribution  of  the 
paralysis  is  unilateral,  bilateral,  or  paraplegic,  into  three  groups:  (i)  Hemi- 
plegia; (2)  bUateral  hemiplegia,  or  diplegia;  and  (3)  paraplegia. 

In  225  cases  reported  by  Peterson  and  Sachs,  the  distribution  was  as  follows: 
Right  hemiplegia,  81;  left,  75;  diplegia,  39;  paraplegia,  30. 

In  150  cases  collected  by  Osier,  120  were  hemiplegic,  19  were  diplegic, 
and  II  were  paraplegic.  The  sexes  are  about  equally  affected.  In  Osier's 
120  cases  of  hemiplegia,  57  were  boys  and  63  girls. 

The  age  at  which  these  different  forms  are  most  common  is  interesting. 
Of  the  hemiplegic  cases  two-thirds  have  their  onset  in  the  first  three  years  of 
life,  and  a  smaller  proportion  occurs  at  birth  and  a  few  only  are  prenatal.  Thus, 
Freud  has  collected  594  cases,  of  which  76  cases  were  congenital,  162  were 
during  first  year,  139  second  year,  81  third  year,  36  fourth  year,  10  fifth  year, 
75  sixth  to  tenth  year.  Of  the  diplegic  cases  the  large  majority  date  from 
birth  as  the  result  of  injury.  Of  the  paraplegic  cases  the  majority  are  congenital, 
a  small  proportion  only  occurring  within  the  first  years  of  life. 


648  ORTHOPEDIC  SURGERY. 

Etiology. 

The  exact  significance  of  many  attendant  or  preceding  diseases,  and  of 
environment  and  heredity,  as  etiologic  factors  is  difficult  to  estimate.  At  best 
the  etiology  is  obscure.  Among  the  predisposing  factors,  however,  may  be 
mentioned  consanguineous  marriages,  alcohoHsm  either  chronic  or  at  time  of 
conception,  hereditary  syphUis,  and  a  certain  fanuly  tendency  to  lesions  of 
the  nervous  system  and  malnutrition.  The  exciting  causes  are  usually  divided 
into  three  classes  according  to  the  time  of  their  occurrence:  first,  prenatal  or 
intrauterine;   second,  natal  or  birth-palsies;   and  third,  post-natal. 

Among  the  prenatal  causes  the  most  important  are  traumatisms;  serious 
maternal  infections  or  septic  diseases  (in  some  of  which  cases  the  fetus  may 
be  simultaneously  affected),  such  as  t)rphoid,  influenza,  pneumonia,  nephritis, 
endocarditis,  and  the  exanthemata;  developmental  arrest  in  development  of 
the  brain,  or  deformity  of  the  skull;  and  prematurity.  In  rare  cases  cerebral 
hemorrhage  and  softening  from  vessel  occlusion  may  occur.  Congenital 
hydrocephalus  is  rarely  a  cause  because  of  the  small  percentage  of  survivals. 

Of  the  natal  causes,  long,  difiicult,  and  instrumental  labors,  particularly 
in  first-born  children,  are  easily  demonstrable.  In  some  cases,  however,  pre- 
cipitate labor  may  cause  marked  compression  and  asphyxiation.  Asphyxia 
neonatorum  is  also  a  cause.  The  lesions  produced  by  meningeal  hemorrhage 
in  birth  injuiries,  as  shown  by  McNutt,  occur  at  the  base  of  the  brain  in  vertex 
presentations,  and  on  the  convexity  in  breech.  Mechanical  obstacles  on  the 
part  of  the  mother,  such  as  produce  great  compression  in  the  superior  strait, 
and  asphyxia  from  long  labor,  are  far  more  important  causes  than  the  use  of 
instruments,  which  may,  in  fact,  sometimes  prevent  the  occurrence  of  cerebral 
hemorrhage. 

Of  the  post-natal  causes,  the  post-febrUe  processes  of  infectious  and  other 
diseases,  such  as  diphtheria,  scarlet  fever,  variola,  vaccinia,  and  varicella, 
measles,  mumps,  whooping-cough,  tonsillitis  and  gastro-enteritis,  t3rphus, 
typhoid,  dysentery,  cerebrospinal  fever,  influenza,  etc.,  are  the  most  important. 
In  whooping-cough  and  violent  vomiting  cerebral  hemorrhage  may  occur. 
Hydrocephalus,  and  focal  polioencephalitis,  are  also  causes.  Traumatisms 
are  comparatively  common  causes.  Thrombosis  at  times  occurs  in  endo- 
carditis and  other  ulcerative  conditions;  and  hemorrhage  from  syphilitic  end- 
arteritis is  the  most  common  syphilitic  lesion.  While  the  majority  of  the 
diplegic  cases  wUl  be  found  to  be  syphilitic,  but  few  of  the  hemiplegic  arise 
from  this  cause.     Sachs  and  Osier  both  believe  that  in  rare  cases  convulsions 


INFANTILE  CEREBRAL  PALSIES.  649 

may  give  rise  to  hemiplegias  and  diplegias;  such  as  the  crcurrence  of  cerebral 
hemorrhage  as  the  result  of  severe  peripheral  irritation  in  dentition  or  tox- 
emias. 

Of  the  congenital  cases,  fright  and  strong  emotion  during  pregnancy  and 
premature  delivery,  especially  at  the  seventh  month,  deserve  especial  prominence. 
The  same  may  be  said  of  traumas,  particularly  cerebral  hemorrhages  in  birth 
palsies,  and  the  influence  of  the  infectious  diseases  in  the  palsies  coming  on 
during  the  first  years  of  life. 

Infantile  Hemiplegia. 

Synonyms. — English,  Spastic  Paralysis.  French,  Agenese  Cerebrale; 
Sclerose  Cerebrale;  Atrophic  Partielle  Cerebrale.  German,  Hemiplegia  Spastica 
Infantiles;  Hemiplegia  Spastica  Cerebralis;  Akut  Encephalitis  der  Kinder; 
Atrophische  Cerebrallahmung.  Italian,  Paralisi  spastica;  Emiplegia  spastica 
infantile.     Spanish,  Hemiplegia  infantile. 

Symptomatology. — There  is  often  present  before  the  onset  of  paralysis 
a  slight  febrile  attack,  infectious  or  otherwise,  an  acute  attack  resembling  indi- 
gestion, or  a  history  of  a  fall  or  blow  on  the  head.  The  onset  is  usually 
characterized  by  a  series  of  convulsions  and  coma,  though  the  disease  may 
develop  suddenly  in  apparently  perfectly  healthy  children  without  spasms  or 
loss  of  consciousness,  or  may  develop  insidiously  without  disturbance  of  any 
kind.  Again,  the  onset  may  be  accompanied  by  delirium  or  screaming-spells. 
A  latent  gradual  onset  is  most  common. 

The  paralysis  affects  the  sexes  about  equally;  thus,  of  692  cases  recorded 
by  Freud,  374  were  on  the  right  side  and  318  were  on  the  left  side. 

The  convulsions  are  almost  always  accompanied  by  loss  of  consciousness, 
lasting  from  a  few  hours  to  many  days.  Fever,  transient  or  persisting  for  weeks, 
is  present  in  a  large  proportion  of  cases.  Vomiting  and  general  hyperesthesia 
are  sometimes  observed.  When  consciousness  is  recovered,  the  hemiplegia 
is  usually  complete;  but  occasionally  loss  of  power,  at  first  not  complete, 
gradually  becomes  so.  In  about  one-half  the  cases  the  face  is  paralyzed,  and 
in  these  it  is  not  complete,  and  rapid  and  complete  disappearance  is  the  rule. 

The  arm  is  more  severely  affected  than  the  leg,  recovers  more  slowly,  and 
rarely  recovers  the  more  delicate  movements.  Arrest  of  development  may 
occur,  but  a  moderate  degree  of  atrophy  is  usual.  The  leg,  at  first  powerless, 
recovers  more  rapidly  and  more  completely.  Arrest  of  development  is  rare, 
and  atrophy  is  never  so  marked  as  in  the  arms.     The  paralyzed  arm  and  leg 


650 


ORTHOPEDIC  SURGERY. 


may  remain  flaccid  for  ever,  but  rigidity  is  present  in  the  large  proportion  of 

cases,  and  comes  on  at  a  variable  period  after 
the  onset.  The  rigidity  is  increased  by  emo- 
tion or  by  attempts  to  use  the  limb  or  forcibly 
overcome  the  spasm,  and  disappears  during 
sleep  and  under  anesthesia. 

During  voluntary  movements  the  rigidity 
has  associated  with  it  ataxic  and  choreiform 
movements,  and  choreiform  movements,  athe- 
toid  movements,  and  tremors  may  occur  in- 
voluntarily. 

The  reflexes  are  usually  increased,  sensa- 
tion is  often  unaffected,  and  vascular  sluggish- 
ness is  marked  by  coldness  and  blueness  of  the 
skin  in  severe  cases.  The  electric  reactions 
remain  practically  unaffected. 

Hemianesthesia  occurs,  but  may  not  at- 
tract attention  on  account  of  the  youth  of  the 
patient.  Hemianopia  is  frequently  present 
and  may  lead  to  torticollis. 

Aphasia  is  observed  in  about  one-third  of 
all  the  cases ;  in  some  transitory,  in  others  per- 
sistent. Post-hemiplegic  movements  in  a  cer- 
tain proportion  of  cases — about  one-fifth — 
follow  at  a  later  stage.  These  have  been 
referred  to  by  different  observers  as  post- 
hemiplegic tremor,  post-hemiplegic  chorea, 
mobile  spasm,  athetosis,  hemiataxia,  and 
chorea  spastica. 

These  consist  of  convulsive  movements  of 
the  affected  parts,  incoordinate  and  chorei- 
form in  character.  Mental  defects,  from 
complete  idiocy  to  a  feeble-minded  condition, 
are  frequently  found  associated  with  infantile 
hemiplegia,  and  three  grades  may  be  dis- 
tinguished :  idiocy,  imbecility,  and  slight  back- 
wardness.    The  lesser  degree  of  mental  defect  is  met  with  in  the  majority  of 


Fig.  474. — Cerebral  Hemiplegia. 


INFANTILE  CEREBRAL  PALSIES.  651 

cases.  Of  26  cases  recorded  by  Bradford  and  Lovett,  only  6  had  what  was 
classed  as  average  intelligence;  in  Gaudard's  80  cases  15  were  feeble-minded 
and  19  idiotic  children;  in  Wallenberg's  160  there  were  50  with  mental  defects, 
and  in  15  more  imbecility  followed  the  epilepsy;  while  in  Osier's  120  cases 
only  12  of  the  infirmary  series  had  idiocy  or  imbecility  at  the  time  of  observation; 
and  all  of  the  23  cases  at  the  Pennsylvania  Institute  for  Feeble-Minded  Children 
had  some  degree  of  idiocy  or  imbecility. 

Epilepsy,  at  first  confined  to  the  paralyzed  side,  but  tending  to  become 
generalized,  attacks  sooner  or  later  a  considerable  proportion,  from  a  quarter 
to  a  half  of  all  the  cases.  The  most  common  form  is  the  true  Jacksonian 
epilepsy. 

Post-hemiplegic  contractions  of  a  permanent  nature  are  most  marked  in 
the  upper  extremity.  In  severe  cases  the  arm  is  held  to  the  side,  the  elbow 
flexed  and  semi-pronated,  the  hand  flexed,  and  the  fingers  contracted  upon 
and  embracing  the  thumb  in  the  palm  of  the  hand.  The  thigh  is  flexed  and 
adducted  at  the  hip,  the  knee  flexed  and  rigid,  and  the  foot  held  in  a  position 
of  equinus  or  equinovarus.  These  contractures  are,  moreover,  very  firm  and 
resistant. 

Bilateral  Spastic  Hemiplegia. 

Synonyms. — English,  Spastic  Rigidity;  Spastic  Rigidity  of  the  Newborn ; 
Spastic  Paralysis  of  Children;  Tonic  Contraction  of  Extremities;  Spastic 
Diplegia;  Essential  Contraction.  French,  Spasme  Musculaire  Idiopathique. 
German,  Permanenter  Kinder-Tetanus.  Italian,  Malo  de  Little;  Spasimo 
musculare  idiopatico  dei  bambini.  Spanish,  Hemiplegia  spastica  bilateral. 
In  France  the  disease  is  sometimes  spoken  of  as  Little's  disease  (maladie  de 
Little),  and  Gowers  has  applied  the  name  birth  palsies,  since  in  the  large 
proportion  the  trouble  dates  from  birth. 

Symptomatology. — Bilateral  hemiplegia  is  characterized  by  spastic 
condition  of  the  extremities.  This  is  observed  immediately  after  or  shortly 
succeeding  birth,  but  occasionally  it  follows  convulsions  in  one  of  the  specific 
fevers. 

The  arms  may  be  but  slightly  affected.  The  legs  are  rigidly  extended, 
and  the  thighs  firmly  adducted — the  so-called  "clasp-knife  rigidity";  the  feet 
are  crossed  and  in  a  varus  or  equino-varus  position. 

On  attempting  to  walk,  the  gait  is  awkward  or  movement  is  impossible. 
The  arms  are  flexed  and  held  firmly  to  the  sides,  and  the  use  of  the  hands  is 


652  ORTHOPEDIC  SURGERY. 

extremely  awkward.     The  extremities  are  not  atrophied.     Sensation  is  unim- 
paired, the  reflexes  are  increased,  and  the  electric  reactions  are  unchanged. 

Three  types  of  attitudes  have  been  described  by  Taylor  ("  Nervous  Dis- 


FlG.    475.  —  CONGEXIIAL    DIPLEGIA        EaRLY    StAGE. 


Fig.  476. — CoxGExiT.iL  Diplegia.    L.a.te  Stage.    Left  Foot  Talipes  Cavus. 

eases  in  Childhood,"  1905) — the  cramped  attitude,  the  attitude  of  adoration, 
and  the  e.xtension-supination  position. 

Spasm   of  the   affected  parts  with  disordered  movement,   and   variously 
described  as  chorea  spastica  and  double  athetosis,  is  not  uncommon,  and  the 


INFANTILE  CEREBRAL  PALSIES. 


653 


so-called  congenital  chorea  is  only  another  name  for  the  same  symptom.  Spasm 
of  the  muscles  of  the  face  and  tongue  is  sometimes  observed.  Strabismus 
and  nystagmus  exist  in  some  instances.  The  mental  condition  is  seriously 
impaired,  the  patients  being  usually  imbeciles  or  idiots.  In  some  instances, 
however,  intelligence  is  fair.  Microcephalus,  with  or  without  asymmetry, 
is  common.  The  facial  expression  is  vacant,  the  teeth  are  defective,  and 
dribbling  from  the  mouth  is  constant. 

Epilepsy  is  not  so  frequent  as  in  hemiplegia. 

Spastic  Paraplegia. 

Synonyms. — English,  Tetanoid  Pseudo-paraplegia;  Deformity  with  Rigid 
Muscles;  Spastic  Spinal  Paralysis;  Spastic  Contractions;  Permanent  Tetanus 
of  the  Extremities.     French,  Tabes  Dorsalis   Spasmcdique.     German,   Para- 


MK^y 

Hi 

^^^^H 

HHttr   '^ 

'"  -^ 

l3S*^^ 

i^H^^mm^^^^^H 

_ 

1 

Mi 

gj 

2^1^ 

Fig.  477- — Photograph  of  Case  or  Cerebral  Palsy,  showing  Spastic  Contractures  of  Upper  and 

Lower  Extremities. 


plegia  Cerebralis  Spastica.     lia.ian,  Spasimo  tabetico;  Paralisi  spinale  spastica. 
Spanish,  Paraplegia  spastia. 

Symptomatology. — In  children  the  condition  usually  appears  at  birth, 
or  within  the  first  year,  although  it  may  occur  later.  The  lower  limbs  are 
drawn  by  the  strongest  muscles  into  a  condition  of  spasmodic  rigidity,  the 
thighs  flexed  upon  the  pelvis  and  slightly  adducted,  producing  the  "clasp-knife 
rigidity,"  the  knees  flexed  and  firmly  adducted,  so  that  they  touch,  or  even 
overlap,  the  feet  inverted  and  strongly  extended  in  a  position  of  extreme  equino- 
varus.  The  contractions  readily  yield  to  firm,  continuous  manual  pressure 
like  a  bit  of  lead, — "lead  pipe  contraction," — but  immediately  return  upon 
its  removal.  The  child  stands  with  assistance,  resting  upon  the  ball  of  the 
foot  and  toes,  and  walks,  if  at  all,  with  a  rapid,  swinging,  irregular  gait,  typical 
of  the  disease,  and  with  the  knees  overlapping  at  every  step,  the  so-called  cross- 


654 


ORTHOPEDIC  SURGERY. 


legged  progression.  The  feet  drag,  wearing  out  the  shoe  caps,  and  the  clothing 
at  the  inner  side  of  the  knees  is  worn  by  constant  friction.  This  stiffness  is 
usually  first  discovered  by  the  mother  in  washing  and  dressing  the  child,  and 
the  child  is  usually  late  and  awkward  in  .attempting  to  walk.     There  is  usually 

no  anesthesia,  ataxia,  atrophy, 
or  any  vesical  or  rectal  incon- 
tinence. There  is  no  loss  of 
equilibrium  in  standing  with 
the  eyes  closed,  and  the  re- 
flexes are  exaggerated. 

In  the  upper  extremity  the 
same  condition  exists,  but  to  a 
less  degree.  The  arms  are 
approximated  to  the  side,  the 
forearm  slightly  flexed,  and  the 
hands  flexed  and  pronated.  The 
flexors  of  the  trunk  are  some- 
times contracted,  and  the  head 
may  be  drawn  forward  and  to 
one  side,  as  in  wry-neck.  Stra- 
bismus may  occur  early,  and 
occasionally  persist.  The  con- 
figuration of  the  head  at  times 
resembles  that  of  the  idiot,  and 
\vith  the  half-silly,  vacant  stare, 
and  an  imperfect  speech,  pre- 
sents the  appearance  of  a  lack 
of  intelligence  which  does  not 
always  exist.  In  fact,  in 
spastic  paraphlegia  the  cere- 
brum is  less  profoundly  af- 
fected than  in  either  of  the  other  two  forms,  and  some  patients  are  inteUigent 
and  bright  intellectually. 


Fig.  478. — Sp.^stic  Paralysis.     Little's  Disease  (Lange). 


Cerebral  Palsies. 

Pathology. — The  pathologic  lesions  are  so  variable,  and  the  subject  itself 
is  so  extensive,  that  it  is  only  possible  in  this  connection  to  give  a  resume  of 


INFANTILE  CEREBRAL  PALSIES.  655 

the  most  recent  matter.  The  pathology  of  infantile  hemiplegia  and  diplegia 
has  received  much  attention,  but  the  morbid  lesion  in  paraplegia  remains  at 
present  less  extensively  studied.  The  morbid  lesions  in  all  three  forms 
differ  mainly  only  in  localization,  and  are:  first,  from  defective  development, 
either  of  the  neurons  themselves  or  the  brain  tissue  locally  or  generally;  sec- 
ond, atrophy  and  retarded  development,  with  subsequent  descent  of  the  de- 
generation through  the  pyramidal  tracts  and  lateral  columns;  and,  third,  a 
destructive  process  in  some  portion  of  the  motor  tract  of  the  cortico-spinal 
segment.     In  general,  it  may  be  asserted  that  the  prenatal  cases  are  in  most 


FiG^  479. — Cerebral  P.axsy.  Contracture  of  Foot. 

instances  thrombotic  in  origin  from  endarteritis,  those  occurring  at  birth  are 
the  result  of  traumatism,  and  those  occurring  later  in  life  are  from  encephalitis. 

In  infantile  hemiplegia.  From  a  study  of  ninety  autopsies,  his  own 
and  abstracted  from  various  sources,  in  cases  occurring  in  infancy  or  childhood, 
Osier  has  grouped  the  lesions  which  occur  under  three  headings: 

1.  Embolism,  thrombosis,  and  hemorrhage. 

2.  Atrophy  and  sclerosis. 

3.  Porencephalus. 

There  were  sixteen  of  the  first,  fifty  of  the  second,  and  twenty-four  of  the 
third  group.  Atrophy  with  induration,  either  of  groups  of  convolutions,  or  an 
entire  hemisphere,  was  noted  variously  distributed  over  the  cerebral  cortex, 
and  in  all  the  recent  cases  a  descending  degeneration  of  the  pyramidal  tract 
was  found.     Audrey  also  found  that  in  103  cases  of  porencephalus  there  were 


656  ORTHOPEDIC  SURGERY. 

hemiplegic  symptoms  in  68.  Out  of  78  cases  of  infantile  hemiplegia  collected 
by  Sachs  and  Peterson,  23  presented  hemorrhagic  lesions,  seven  embolism, 
and  five  thrombosis.  These  were  all  of  birth  or  post-natal  origin.  The  primary 
cause  in  the  majority  of  cases  presenting  sclerotic  changes  and  porencephalia 
is  unknown.  Porencephalia  may  be  the  result  of  a  congenital  lack  of  develop- 
ment, or  may  be  the  result  of  an  initial  lesion  long  past  and  originally  a  hemor- 
rhage. 

Plugging  of  the  sylvian  artery,  usually  embolic,  occurred  in  seven,  and 
hemorrhage  in  nine.  Atrophy  with  induration,  either  of  groups  of  convolutions, 
a  lobe,  or  an  entire  hemisphere,  was  noted  variously  distributed  over  the  cerebral 
cortex,  and  in  all  the  recent  cases  a  descending  degeneration  of  the  pyramidal 
tract  was  found.  Porencephalus,  meaning  literally  "a.  hole  in  the  brain," 
represents  a  loss  of  substance  of  variable  size,  from  a  few  convolutions  to  half 
a  hemisphere,  in  the  form  of  cysts  or  cavities  f\ill  of  liquid,  and  clots,  cerebral 
h3rpertrophy  or  atrophy,  undersized  and  irregularly  marked  brain,  agenesis 
corticalis  of  Sachs  (in  which  all  strata  and  layers  of  the  cortex  may  be  absent 
largely  and  especially  the  layer  of  great  pyramidal  cells),  macrogyria,  or  soft- 
ened and  hemorrhagic  areas  with  torn  vessels,  round-cell  infiltration,  granular 
cells  and  nuclear  proliferation  the  result  of  a  focal  or  diffuse  encephalitis  follow- 
ing traumatism. 

These  lesions  represent  the  final  results  of  initial  processes  long  past  and 
originally  a  hemorrhage,  an  encephalitis,  or  other  post-febrile  change.  In 
birth  palsies  the  main  lesion  is  hemorrhage,  which  is  rarely  intra-cerebral, 
but  generally  meningeal.  The  later  conditions  show:  meningo-encephalitis 
chronica;  sclerotic  or  cystic  changes;  and  partial  atrophic  changes.  In  the 
acquired  or  post-natal  palsies  are:  (i)  hemorrhage  from  traumatism  or  con- 
gestion during  violent  convulsions  or  a  paroxysm  of  whooping-cough;  (2)  em- 
bolism from  endocarditis  or  post-febrUe  causes;  (3)  other  post-febrile  causes, 
such  as  endo-arterial  and  peri-arterial  changes  and  encephalitis;  and  (4)  throm- 
bosis of  the  cerebral  veins  caused  by  diseased  and  roughened  vessels  (mainly 
syphilitic),  very  weak  heart  action,  and  the  blood  in  specific  febrile  diseases. 

It  has  been  suggested  by  Striimpell  that  the  lesion  was  the  cerebral  counter- 
part of  infantile  spinal  palsy — a  poliencephalitis  of  the  motor  areas  of  the  cortex, 
analogous  to  poliomyelitis  of  the  anterior  horns— a  very  suggestive  theory, 
but  one  which  has  not  been  confirmed  by  the  pathologic  findings,  nor  has  it 
met  with  the  favor  it  deserves  from  neurologists,  since  anatomical  proof  is 
lacking. 


INFANTILE  CEREBRAL  PALSIES.  657 

It  is  probable  that  infantile  hemiplegia  is  the  result  of  a  variety  of  dif- 
ferent processes,  of  which  the  following,  according  to  Osier,  are  the  most 
important : 

1.  Hemorrhage,  occurring  during  violent  convulsions  or  during  a  par- 
oxysm of  whooping-cough. 

2.  Post-febrile  processes:  (a)  embolic;  (b)  endo-arterial  and  peri-arte- 
rial changes;   and  (c)  encephalitis. 

3.  Thrombosis  of  the  cerebral  veins. 

In  bilateral  spastic  hemiplegia,  which  is  usually  the  result  of  a  birth 
palsy,  the  pathologic  lesion  is  in  all  probability  bilateral  atrophy,  sclerosis,  or 
porencephalous  defect  of  the  motor  areas  of  the  cortex  cerebri. 

In  the  reports  of  numerous  autopsies  this  is  the  lesion  usually  observed, 
and,  in  many,  descending  degeneration  in  the  p3T:amidal  tracts  has  been 
found. 

In  infantile  spastic  paraplegia  the  pathologic  lesion  involves  the  pyramidal 
tracts  and  is  generally  the  extension  of  a  cortical  lesion.  It  is  not  improbable 
that  some  cases  may  be  due  to  spinal  hemorrhage,  and  that  traction  in  feet 
presentation  might  injure  the  pyramidal  tracts  and  be  followed  by  sclerosis, 
or  that  it  might  result  from  injury  inflicted  upon  the  medulla  during  efforts 
at  resuscitation. 

In  the  one  recorded  autopsy,  that  of  Forster,  the  cord  changes  were  re- 
garded as  a  descending  degeneration,  the  consequence  of  cerebral  lesion.  The 
most  plausible  view  is  that  the  lesion,  originally  cerebral,  has  more  or  less 
completely  disappeared  and  left  the  secondary  descending  degenerative  cord- 
changes  as  the  most  conspicuous  feature.  It  has  also  been  ascribed  to  pri- 
mary sclerosis  of  the  lateral  columns  (crossed  pyramidal  column),  to  various 
lesions  of  the  spinal  cord,  chiefly  myelitis,  meningitis,  micro-cephalia,  poren- 
cephalia, and  anencephalia,  and  to  genital  or  other  peripheral  irritation. 

Diagnosis. — The  characteristic  signs  of  this  group  of  cases  are  the 
spastic  tetanoid  condition  of  the  extremities,  the  distribution  of  the  motor  par- 
alysis, the  absence  of  atrophy  in  the  affected  parts,  with  increased  reflexes, 
and  unchanged  electric  reactions,  with  or  without  mental  defect.  These  form 
a  comprehensive  picture  that  can  scarcely  be  mistaken  for  any  other  affection 
except  idiocy  uncomplicated  by  spastic  paraplegia.  In  this  condition  there 
is  a  relaxed,  flaccid  condition  of  the  muscles,  the  child  sits  and  stands  with 
difficulty,  and  there  are  absent  both  localized  paralysis  and  muscular  rigidity. 

Differential  Diagnosis. — From  infantile  spinal  paralysis,  with  which 
43 


658  ORTHOPEDIC  SURGERY. 

it  is  most  frequently  confounded,  cerebral  paralysis  has  been  very  carefully 
differentiated  in  the  preceding  chapter. 

In  infantile  spinal  paralysis  the  sudden  paralyis  is  accompanied  by  early 
loss  of  reflexes,  absence  of  rigidity,  and  marked  electric  reaction  changes,  while 
in  the  infantile  cerebral  palsies  the  paralysis  is  accompanied  with  spasm  and 
disordered  movements,  increased  reflexes,  gradual  and  slight  wasting,  and  normal 
electric  reactions. 

The  hemiplegia  must  also  be  distinguished  from  obstetric  paralysis,  cerebral 
tumor,  and  the  diplegia  and  paraplegia  from  pseudo-paralytic  rigidity  met 
in  children. 

Cerebral  tumors  sometimes  produce  symptoms  identical  with  cerebral 
palsies  and  ordinarily  cannot  be  distinguished. 

Obstetric  paralysis  of  the  face  or  upper  extremity  from  forceps  injury 
is  a  peripheral  lesion  and  need  not  be  confounded  with  palsies  of  cerebral 
origin. 

Pseudo- paralytic  rigidity,  described  also  as  idiopathic  contraction  with 
rigidity,  and  tonic  rigidity  of  the  extremities,  is  apt  to  be  confounded  with 
true  spastic  paralysis.  The  fact  that  it  is  a  painful  carpo-pedal  spasm,  inter- 
mittent, transitory,  often  confined  to  the  hands  and  arms,  and  associated  with 
rickets  or  other  constitutional  disturbance,  would  serve  to  distinguish  it. 

Spastic  paraplegia  in  a  mild  form  sometimes  resembles  beginning  pseudo- 
hypertrophic paralysis,  and  in  such  cases  time  alone  can  settle  the  diagnosis. 
Diplegic  cases  are  sometimes  confounded  with  grave  hysteric  conditions,  but 
the  administration  of  an  anesthetic  will  cause  a  complete  disappearance  of  all 
spasticity  in  the  latter  condition. 

Prognosis. — The  prognosis  will  depend  much  upon  the  character  and 
extent  of  the  initial  lesion,  hemorrhage  and  vascular  obstruction  being  more 
favorable  than  meningo-encephalitis,  and  the  latter  than  intracranial  growths. 

In  the  traumatic  cases  it  should  not  be  forgotten  that  complete  spontaneous 
recovery  sometimes  occurs. 

In  intracranial  growths  surgical  interference  offers  a  bright  prospect  for 
cure,  the  success  of  the  operation  depending  largely  upon  the  character  of  the 
growth — infiltrating  or  noninfiltrating — and  its  accessibility.  Many  brilliant 
successes  have  been  reported. 

In  regard  to  the  bodily  defect,  while  great  improvement  may  be  predicted, 
perfect  recovery  is  rarely  attained.  Facial  paralysis  and  aphasia  usually  dis- 
appear.    Post-hemiplegic  movements  and  epilepsy  are  bad  prognostic  signs. 


INFANTILE  CEREBRAL  PALSIES. 


659 


Fig.  480. — Cerebral  Palsy,  Diplegic  Type, 
SHOWING  Contraction  of  Arm  before  Ten- 
don-lengthening . 


In    hemiplegic    and   diplegic    cases   the   mental    enfeeblement    is    distressing 
and   grave,    and    while   training   may   do    much    to    improve,    the   prognosis 
for  many  is  bad,  since   they  are  liable   late   in   life   to  become   the  subjects 
of  psychoses.     Many  of   these  chil- 
dren live  to  be  over  twenty  years  of 
age.      In    spastic    paraplegia,    while 
perfect   recovery  is  impossible,  most 
children    learn    to    walk    and    talk 
imperfectly,    and   operative    interfer- 
ence  is   of  great  value,  for,   as  my 
own   operations  have   demonstrated, 
tenotomy  not  only  improves  the  po- 
sition of  the  limbs,  but  also  decidedly 
benefits  the  mental  condition. 

While  the  prospects  of  life  are 
good,  the  vital    resistance  is    not  great,   and   there    is   a   greater  liability  to 
death   from  intercurrent   affections,   and,   according  to   some   authorities,   all 
cases  of  cerebral  palsy  are  particularly  liable  to  fatal  meningitis. 

Treatment. — The  convulsions  and  coma  which  characterize  the  onset 
require  the  same  general  treatment  as  convulsions  from  other  causes— a  hot 
bath  with  cold  to  the  head,  a  calomel  purge,  and  bromids  and  chloral.  After 
the  paralysis  is  established  the  indications  are  to  favor  the  natural  tendency 

to  improve,  to  maintain  the 
nutrition  of  the  palsied  parts, 
and  correct  the  deformities  by 
proper  surgical  and  mechani- 
cal measures.  Daily  massage, 
warm  clothing,  and  electricity 
will  be  of  great  benefit  in 
maintaining  the  nutrition  and 
temperature  of  the  affected 
parts.  Gymnastic  exercises  will 
be  found  of  great  value,  and 
Fraenkel  exercises  are  quite  as 
valuable  for  children  as  for  adult  ataxics.  The  coordination  may  be  devel- 
oped by  the  use  of  bells,  letter  cards,  etc.,  and  the  writer  has  found  these 
means    of    great    service.      The    electricity  must   be    applied    faithfully  and 


Fig.  481. — Same,  after  Tendon-lengthening. 


660 


ORTHOPEDIC  SURGERY. 


persistently  for  a  long  period.  For  the  spastic  rigidity  and  contractures, 
persistent  massage  with  strong  flexion  and  extension  of  the  extremities  is 
beneficial. 

Circumcision  may  be  of  service  where  genital  irritation  is  evidenced  by 
balanitis,  painful  micturition,  and  frequent  erections.  In  a  certain  number 
of  cases,  however,  it  has  no  effect  whatever,  or  is  only  temporarily  beneficial. 


Fig.  482. — Infantile  Spinal  Palsy  before  Operation. 


Fig.  483. — Same,  after  Operation. 


Tenotomy  and  tenoplasty  offer  the  greatest  hope  in  these  cases.  In 
diplegia  little  will  be  gained  by  operation,  but  in  hemiplegia  and  paraplegia 
and  in  the  post-hemiplegic  contractions  following,  great  benefit  will  ensue. 
The  tendons  that  require  division  most  frequently  arc  the  tendo  Achillis, 
adductors   of  foot,    hamstring,   and   adductors  of  the  thigh.     They  should  be 


INFANTILE  CEREBRAL  PALSIES. 


661 


performed  as  described  in  Part  I.     After  the  operation  the  parts  should   be 
immediately  over-corrected  and  fixed.     No  attempt  need  be  made  to  straighten 
the  contracted  parts  by  mechanical  stretching,  but  tenotomy  may  be  at  once 
resorted  to,  since,  as  before  remarked, 
the  effect  upon  the  mental  condition  is 
also    beneficial.      After   operation    an 


Fig.  484. — Active  Tr.\nsplantation  of  a  Portion  or  the 
Flexor  Carpi  Radialis  Tendon  to  the  Extensor 
Communis  Digitorum. 

I,  Portion  of  tendon  of  the  flexor  carpi  radialis;  2,  tendon  of  the 
flexor  carpi  radialis  (Berger  and  Banzet). 


Fig.   485. — Suture   of   the    Flexor   Carpi   Radialis   to 

the  Extensor  Communis  Digitorum. 
I,  Tendon^of  the  flexor  carpi  radialis;  2  and  3,  tendons  of  the 

extensor  communis  digitorum;  4,  tendon  of  the  extensor 

minimi  digiti. 


ordinary  varus  walking-shoe  with  stop-joints  at  the  ankle,  or  a  Congden  apparatus 
extending  above  the  knee,  with  locking  and  unlocking  joint  to  fix  the  knee, 
should  be  worn  for  some  time,  after  which  it  may  be  permanently  discarded. 
Tendon  grafting  has  a  limited  application  in  hemiplegia,  the  operation 


C62 


ORTHOPEDIC  SURGERY. 


of  Hoffa  being  beneficial  in  selected  cases.  This  consists  in  detaching  the 
head  of  the  pronator  radii  teres  from  its  origin  on  the  internal  condyle  and 
attaching  it  to  the  external  condyle  of  the  humerus.  Then  the  flexor  carpi 
ulnaris  and  flexor  carpi  radialis  are  detached  from  their  insertions  and  attached 

to  the  tendons  of  the  extensor  communis 
digitorum.  In  this  way  the  supination 
and  extension  of  the  hand  arc  improved. 


Fig.  486. — Suture  of  the  Radial  Tendons  to  the  Abduc- 
tors AND  the  Extensors  of  the  Thumb. 

I,  Portion  of  the  extensor  carpi  radialis  brevior;  2,  tendon  of 
the  e.xtensor  carpi  radiahs  brevior;  3,  tendon  of  the  exten- 
sor carpi  radialis  longior;  4,  tendon  of  the  extensor  longus 
poUicis;  5,  tendon  of  the  extensor  brevis  pollicis  (Berger 
and  Banzet). 


Fig.  487. — Transplant.\tion  of  the  Large  and  Sm.\ll]^P.\ljjar 

Tendons  to  the  Extensors  of  the  Fingers. 
I,  Internal  half  of  the  palmaris  longus;  2,  tendon  of  the  palmaris 

brevis;  3,  palmaris  longus;  4,  insertion  of  the  palmaris  brevis 

(Berger  and  Banzet). 


The  final  result  in  tendon  transplantation  depends  somewhat  upon  the  condition 
for  which  it  was  performed.  If  the  mental  intelligence  be  high,  the  functional 
result  will  be  better  than  if  the  mental  condition  were  of  low  grade. 


INFANTILE  CEREBRAL  PALSIES. 


663 


A  successful  nerve  anastomosis  for  athetosis  has  been  proposed  by  Spiller, 
and  performed  by  Van  Kathoden.  It  consisted  in  anastomosing  all  the  divisions 
of  the  brachial  plexus  except  the  musculospiral. 

The  mental  condition  requires  special  training  in  all  these  cases,  and  the 
results  attained  at  institutions  specially  devoted  to  the  training  of  feeble-minded 

children  demonstrate  the  advantages  of 
such  training  in  these  particular  cases. 
Such  training  should  always  be  under 


Fig.    488. — TitANSPLANTATION     OF     THE     LARGE     AND 

Small  Palmar  Tendons  to  the  Extensors  of 
THE  Fingers. 
I,  Internal  fascia  of  the  palmaris  longus;    2,  tendon  of 
the  palmaris  brevis;  3,  extensor  indicis;  4,  extensor 
communis  digitorum  (Berger  and  Banzet). 


Fig.  489. — Transplantation  of  the  Large  and  Small 
Palmar  Tendons  to  the  Extensors  of  the  Fin- 
gers. 

I,  Tendon  of  the  palmaris  longus;  2,  tendon  of  the  palmaris 
brevis;  3,  extensor  longus  poUicis;  4,  extensor  indicis 
(Berger  and  Banzet). 


the  direction  of  a  competent  specialist.  The  development  of  the  mind  through 
manual  training  is  valuable,  as  by  the  Sloyd  system.  Similar  good  results  have 
been  obtained  by  the  Allan  Latshaw  method,  v^fhich  aims  first  to  attract  the 
attention  of  the  individual  through  the  perceptive  faculties,  and  afterward  to 


664  ORTHOPEDIC  SURGERY. 

develop  coordination  through  manual  employment.  Model  farm  scenes, 
pleasure  grounds,  etc.,  are  used  to  interest  the  child,  and  subsequently 
he  is  taught  the  manufacture  of  objects  seen,  and  finally  manual  training 
is  added. 

Operations  on  the  brain  for  the  relief  of  epilepsy  in  cases  of  cerebral  palsy 
have  of  late  been  rendered  possible  wherever  localizing  symptoms  have  been 
present.  Since  the  majority  of  cases  are  due  either  to  (i)  destructive  vascular 
lesion,  apoplectic,  embolic,  or  thrombotic,  (2)  sclerosis,  or  (3)  porencephalus, 
all  of  which  are  beyond  relief  from  surgical  interference,  there  remains 
nothing  but  the  intracranial  growths,  the  prognosis  of  which  has  already  been 
referred  to. 

In  long-standing  cases  the  possible  existence  of  descending  degeneration 
offers  a  serious  objection,  since  the  paralysis  could  not  be  benefited  by 
operation.  Surgical  interference  will  be  found  useless  in  the  majority  of 
cases  of  cerebral  paralysis,  and  when  porencephalus  is  present,  the  paralysis 
due  to  a  hole  in  the  brain  is  not  likely  to  be  improved  by  operation,  con- 
vulsions and  death  usually  resulting  when  such  attempts  are  made.  In  my 
opinion,  craniotomy  is  justifiable  in  cerebral  hemiplegia  in  the  event  of  the 
development  of  severe  Jacksonian  epilepsy  in  early  life  uninfluenced  by  the 
advent  of  puberty. 

Craniectomy  and  asexualization.  The  theory  that  microcephalic  idiocy 
is  due  to  the  premature  ossification  of  the  cranial  sutures  and  a  consequent 
arrest  of  cerebral  growth  has  led  to  the  operation  of  craniectomy,  or  the  removal 
of  a  portion  of  the  skull,  for  its  relief.  In  the  great  number  of  cases  which 
have  been  subjected  to  this  operation  the  mortality  has  been  as  high  as  25 
per  cent.,  the  improvement  in  the  other  cases  being  either  very  slow  and 
gradual  or  altogether  absent.  In  a  dozen  cases  operated  upon  before 
coming  to  him,  Barr  noted  no  improvement  that  could  be  traced  to  the 
operation,  but  rather  found  them  mentally  inferior  to  many  in  their  class. 
Most  authorities  now  agree  that  this  theory  is  untenable,  and  that  the  size 
of  the  skuU  is  determined  by  the  growth  of  the  brain,  rather  than  the 
reverse,  and  that  the  development  of  an  undersized  brain  cannot  be  influenced 
by  craniectomy. 

In  order  to  prevent  the  inheritance  of  idiocy  and  to  protect  the  public, 
asexualization  has  been  proposed,  and  in  certain  states,  as  Connecticut,  has 
been  legalized.  This  is  best  accomplished  by  the  performance  of  oophorectomy 
in  the  female,  and  of  castration  or  vasectomy  in  the  male,  these  operations 


Fig.  490. 


Fig.  49 1. 


Fig.  402. 

Figs.  490-492.— articles  Made  by  Defective  Children. 


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Fig.  494. 

Figs.  493-494.— articles  Made  by  Defective  Children. 


INFANTILE  CEREBRAL  PALSIES. 


669 


being  performed  only  on  low-grade  idiots,  and  then  only  after  the  deliberate 
decision  of  a  board  composed  of  competent  medical  men  and  laymen.  Ford 
reports  26  cases  of  asexualization  in  the  male  in  which  the  effect  upon  the 
epilepsy  was  favorable,  and  Pfeister  reports  116  upon  whom  oophorectomy 
was  performed;  the  menopause  followed  in  94.8  per  cent.;  sexaial  desire  was 
abolished  in  52  per  cent.,  diminished  in  30  per  cent.,  and  unaffected  in  26 
per  cent. 

Amaurotic  Family  Idiocy. 

Sachs  was  the  first  to  report  this  condition,  which  is  mainly  remarkable 
because  of  its  restriction  to  children  born  of  Jewish  parents,  and  for  the  fact 


Fig.  495.  Fig.  496.  Fig.  497. 

Figs.  495,  496,  497. — Craniectomy  for  Cerebral  Palsy  (Barr). 


that  the  onset  usually  cccurs  within  the  fourth  to  the  eighteenth  month.  The 
children  are  usually  healthy  and  their  growth  is  normal  until  the  time  of  onset, 
when  they  become  stupid,  weak,  and  of  diminished  muscular  power.  Their 
condition  gradually  becomes  worse,  and  blindness  due  to  optic  atrophy  com- 
pletes the  clinical  picture.  The  ophthalmoscopic  appearance  is  not,  strictly 
speaking,  that  of  pronounced  atrophy,  but  the  fovea  centralis  "presents  a  clear- 
cut  liver-colored  plaque  surrounded  by  a  halo  of  grayish-white  which  does  not 


670  ORTHOPEDIC  SURGERY. 

obscure  the  retinal  vessels."  Death  usually  supervenes  before  the  second 
year. 

Two  or  more  children  in  one  family  have  been  attacked  with  this  disease, 
but  normal  children  may  be  born  to  the  parents  between  those  affected. 

Sachs  gives  as  the  pathologic  change  an  agenesis  and  degeneration  of  the 
gray  matter  and  even  of  the  root  ganglia  throughout  the  entire  cerebral  axis. 
Frey,  however,  considers  this  disease  as  equivalent  to  amyotrophic  lateral  scle- 
rosis in  the  adult. 


CHAPTER  XX. 

OTHER  PARALYSES. 

There  are  four  other  motor  affections  for  which  the  orthopedic  surgeon 
is  frequently  consulted,  and  which  deserve  brief  notice  here.     These  are: 

1.  Pseudo-hypertrophic  muscular  paralysis. 

2.  Progressive  muscular  atrophy. 

3.  Hereditary  ataxia  (Friedreich's  disease). 

4.  Peripheral  palsies. 

The  first  two  of  these  are  known  as  muscular  dystrophies,  and  Gowers 
has  designated  the  congenital  forms  "muscular  abiotrophy"  to  indicate  the 
premature  senUity  of  the  muscles. 

The  nerve  tract  last  developed  and  the  muscles  least  used  suffer  most,  illus- 
trating the  preservation  of  the  essentials. 

Pseudo-hypertrophic  Muscular  Paralysis. 

Pseudo-hypertrophic  muscular  paralysis  is  an  affection  of  childhood, 
characterized  by  an  abnormal  increase  in  the  size  of  certain  muscles  with  diminu- 
tion in  the  size  of  others. 

Synonyms. — English,  Duchenne's  Paralysis;  Muscular  Pseudo-hypertro- 
phy; Lipomatous  Muscular  Atrophy;  Diffuse  Muscular  Lipomatosis.  French, 
Paralysie  Myosclerosique ;  Paralysie  Musculaire  Pseudo-hypertrophique. 
German,  Lipomatosis  Luxurians  Muscularis  Progressiva;  Myopachynsis 
Lipomatosa.  Italian,  Paralisi  pseudo-ipertrofica  musculare;  Paralisi  di  Du- 
chenne;  Cifomatosi  musculare  diffusa.  Spanish,  Paralisis  pseudohipertrofica 
Muscular. 

Etiology. — The  etiology  is  obscure.  It  usually  appears  between  the 
ages  of  two  and  eight,  and  affects  males  more  frequently  than  females  in  the 
proportion  of  about  four  or  five  males  to  one  female.  Congenital  cases  occur, 
and  in  rare  cases  this  disease  occurs  as  late  as  puberty.  Cases  have  been  known 
to  occur  as  late  as  eighteen  or  twenty  years.  Heredity  is  an  important  factor, 
the  morbid  inheritance  being  usually  maternal,  and  it  is  more  apt  to  occur 
in  families  than  in  isolated  cases. 

671 


672 


ORTHOPEDIC  SURGERY 


The  appearance  cf  the  disease  in  several  members  of  the  family  in  either 
one  or  more  generations;  the  fact  that  the  disease  may  not  always  appear  as 
pseudo-hypertrophic   paralysis,  but   in   some  cases  alternates  with   the  other 
muscular  dystrophies;    the  transmission  through  the  maternal  line;    and  its 
appearance  during  the  age  of  growth  and  develop- 
ment mark  it  as  being  hereditary,  "familial,"  and 
congenital. 

The  disease  is  transmitted  mainly  through  the 
female  members  of  the  family.  Coming,  as  it  does, 
during  childhood,  it  has  in  some  few  instances 
seemed  to  have  followed  some  one  of  the  dis- 
orders of  that  period,  but  this  perhaps  may  be 
accidental.  Diphtheria  has  in  several  instances 
preceded  the  disease;  while  in  other  instances 
there  is  a  history  of  slight  injuries,  exposure  to 
cold,  etc.  When  the  individual  has  a  predisposing 
hereditary  taint,  it  is  quite  plausible  to  state  that 
any  lowering  of  the  resisting  power  may  precipi- 
tate the  disease. 

Pathology. — The  pathologic  changes  consist 
in  degenerative  changes  in  the  muscular  fibers, 
marked  increase  in  the  muscular  connective  tissue, 
an  increased  amount  of  fat  between  the  muscular 
bundles  and  connective-tissue  fibers.  Von  Babes 
has  found  undeveloped  and  disintegrated  muscle 
nerve- plates.  Various  cord-changes  have  been  de- 
scribed, but  no  constant  lesion  is  found,  and  the 
disease  is  at  present  regarded  as  a  primary  mus- 
cular affection — a  tendency  to  excessive  growth  of 
the  muscular  connective  tissues. 

Symptomatology. — The  first  symptoms  ob- 
served are  motor  weakness,  difiiculty  in  going  up 
and  down  stairs,  and  a  peculiar  gait  in  walking. 
The  patients  fall  frequently  and  experience  difficulty  in  rising,  from  muscular 
weakness  of  the  back  and  lower  limbs. 

A    pseudo-muscular    h3^ertrophy    commences    simultaneously   with    the 
motor  weakness  and  is  due  to  a  fattv  infiltration  of  the  affected  muscles.     The 


Fig.  498. — Photograph  of  Case 
of  pseudo  -  hypertrophic 
Muscular  Paralysis. 
Early  Stage. 


OTHER  PARALYSES. 


673 


calf  muscles,  infraspinati,  and  deltoids  first  become  affected,  but  eventually 
in  from  one  to  three  years,  all  the  voluntary  muscles,  with  the  exception  of  the 


i 

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I  •-'^■"'*«****';  J*^ 

Mb 

Fio.    409-— Pseudo-muscular    HYri;inRoi>i[Y,    shoxmxg  Fig.  500.— Same,  showing  Atrophy  of  Back  Muscles; 

Attitude.  and  Enlargement  of  Legs. 


pectorals,  suffer.     This  is  succeeded  by  atrophy,  the  wasting  appearing  first 
and  being  most  marked  in  the  pectorals  and  latissimus  dorsi.     The  posture 


674 


ORTHOPEDIC  SURGERY 


and   gait   in   walking   are   peculiar.     Standing   with   the   feet   widely   apart, 
the    abdomen    projects,    the    lumbar    spine    is    arched    forward    in    marked 
lordosis,    the    buttocks    are    thrown    back   and 
the  shoulders  forward. 


Fig.  501. — Peogressive  Muscular  Atrophy. 


Fig.    502. — PSEUDO-HYPERTROPHIC 

Muscular  Par.alysis. 


OTHER  PARALYSES. 


675 


In  walking  the  center  of  gravity  is  brought  well  over  each  foot  of  the  active 
limb  to  enable  the  passive  leg  to  swing  more  easily  forward,  which  gives  a  peculiar 
swaying  waddle  to  the  gait. 

In  advanced  cases  atrophy  and  contractions  give  rise  to  talipes  equinus, 
flexion  of  knees  and  hip,  and  marked  lordosis  and  scoliosis  of  the  spine.  The 
muscular  contractility  is  lowered  to  both  currents,  knee-jerk  disappears  entirely 
in  advanced  cases,  but  sensation  remains  normal  and  rectal  and  vesical  failure 
seldom  occurs.  Vasomotor  disturbances  are  marked  and  a  mottling  of  the 
limb  is  often  seen.     Mental  weakness  is  often  associated. 

Diagnosis. — In  well-marked  cases  the  attitude,  the  peculiar  walk,    the 


Fig.  503. — Morton  Spinal  Support,  Back  View. 


Fig.  504. — Same,  Front  View. 


enlarged  calf  muscles,  and  particularly  the  association  of  these  symptoms 
with  enlargement  of  the  infraspinati,  with  wasting  of  the  latissimus  dorsi  and 
pectorals,  are  so  characteristic  as  scarcely  to  be  mistaken.  The  peculiar  manner 
in  which  the  patient  rises  from  the  floor  and  assumes  the  erect  position  is  also 
characteristic  of  this  disease. 

The  gait  resembles  that  of  spastic  paraplegia,  the  paraplegia  of  rickets,  and 
of  Pott's  disease;  and  these  will  be  referred  to  in  their  proper  places.  Progres- 
sive muscular  atrophy  is  the  affection  with  which  it  is  most  closely  allied,  and 
from  which  it  is  most  difficult,  and  in  many  instances  impossible,  to  distinguish  it. 
It  is  to  be  distinguished  by  the  fact  that  it  occurs  later  and  the  distribution 
of  the  atrophy  is  different.     In  pseudo-hypertrophy,  the  small  muscles  of  the 


676  ORTHOPEDIC  SURGERY. 

trunk  escape;  in  progressive  muscular  atrophy,  the  affection  usually  begins 
in  these  muscles. 

Prognosis. — The  prognosis  in  established  cases  is  exceedingly  grave. 
Under  proper  treatment  the  disease  has  been  arrested,  and  cases  of  recovery 
have  been  recorded.  Death  occurs  from  exhaustion  or  some  intercurrent 
affection — especially  pulmonary  disease.  The  disease  after  attaining  its 
maximum  may  remain  stationary  for  a  long  time,  and  eventually  prove  rapidly 
fatal.  x\fter  the  power  of  standing  is  lost,  the  patient  will  not  probably  live 
more  than  a  few  years. 

Treatment. — Cases  of  arrest  are  reported  following  the  use  of  electricity. 
In  conjunction  with  systematic  exercise,  gymnastics,  and  massage,  electricity 
oft'ers  the  best  means  of  arresting  the  disease.  Tenotomy  of  the  tendo  Achillis 
is  of  great  service  where  marked  equinus  exists,  and  in  some  cases  tenotomy 
of  the  hamstrings  may  be  performed.  Mechanical  apparatus  is  of  little  or 
no  value,  except  the  occasional  use  of  a  light  spinal  brace  to  relieve  the 
lordosis.     For  this  purpose  the  Morton  brace  (Figs.  503,  504)  may  be  used. 

Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy  is  a  chronic  disease  characterized  by  pro- 
gressive atrophy  of  individual  muscles  or  groups  of  voluntary  muscles,  indepen- 
dent of  any  antecedent  motor  or  sensory  paralysis,  or  of  any  metallic  poisoning, 
and  leading  to  deformity. 

Synonyms. — English,  Wasting  Palsy;  Paralysis  Atrophica;  Cruveilhier's 
Atrophy;  Cruveilhier's  Paralysis.  French,  Atrophic  Musculaire  Progressive. 
German,  Progressive  Muskelatrophie ;   Progressive  Muskellahmung. 

Etiology. — This  is  an  affection  of  early  and  middle  adult  life,  the  earliest 
being  two  years,  and  the  latest  sixty-nine  years  of  age.  The  average  age  of 
onset  is  said  to  be  from  twenty-five  to  fifty  years.  It  affects  more  males 
than  females,  the  proportion  being  about  6  to  i,  possibly  owing  to  muscular 
occupation  and  greater  exposure  of  males. 

Two  forms  have  been  distinguished  by  some  writers:  a  spinal  or  myelo- 
pathic form,  and  a  muscular  or  myopathic  form,  the  former  occurring  after 
puberty  from  disease  or  violence  aft'ecting  the  spine,  and  the  latter  occurring 
congenitally,  often  hereditary,  and  sometimes  influenced  by  consanguinity. 
In  the  spinal  form  various  lesions  are  present — spinal  progressive  muscular 
atrophy,  wasting  palsy,  chronic  poliomyelitis,  amyotrophic  lateral  sclerosis, 
Duchenne's  disease,  and  Charcot's  disease. 


OTHER  PARALYSES.  677 

Three  subdivisions  of  the  myopathic  form  are  recognized,  first  a  fascio- 
scapulo-humeral  form,  myasthenia  gravis,  known  as  the  Landouzy-Dejerine 
t5rpe,  which  primarily  affects  the  face,  shoulder,  and  arm  muscles;  second,  the 
so-called  juvenile  form  of  Erb,  which  primarily  affects  the  upper  arm,  shoulder 
and  pelvic  girdles,  back  and  thigh;  and  third,  the  peroneal  type,  which  begins 
primarily  in  the  extensor  muscles  of  the  toes  and  finally  involves  all  the  muscles 
of  the  leg. 

A  hereditary  form  is  also  recognized  by  some  vreiters,  which  does  not  differ 
in  general  aspects  from  the  usual  myelopathic  form,  but  its  occurrence  in 
individuals  with  a  neuropathic  family  history  is  common. 

The  most  frequent  exciting  causes  are  excessive  muscular  action,  exposure 
to  cold  and  wet,  traumatism  to  head,  neck,  or  spine,  anxiety  and  overwork, 
venereal  excesses,  constitutional  syphilis,  onanism,  and  antecedent  febrile  or 
zymotic  affections.  It  is  a  not  infrequent  sequela  of  acute  poliomyelitis  in 
early  life. 

Pathology. — The  lesions  in  the  spinal  form  may  occur  in  the  entire  motor 
tract  of  the  nervous  systems.  There  may  be  both  peripheral  and  central  lesions. 
In  most  cases  the  lesion  does  not  extend  beyond  the  medulla,  but  rare  cases  in 
which  the  cortex  even  has  been  involved  have  been  reported.  The  degeneration 
in  the  lower  neuron  is  at  first  usually  peripheral,  but  in  all  marked  cases  atrophy 
and  degeneration  of  the  ganglion  cells  of  the  anterior  horn  are- present.  There 
is  also  sclerotic  degeneration  of  the  white  matter  of  the  direct  and  crossed  pyram- 
idal tracts;  and  the  antero-lateral  tracts  are  usually  also  diseased,  especially  in 
the  cervical  and  upper  dorsal  portion  of  the  cord.  There  is  also  a  shrinking  of 
myelin  in  the  columns  of  Goll.  The  anterior  cornual  lesions  are  more  marked 
above  the  dorsal  portion  of  the  cord,  but  the  sclerosis  of  the  crossed  pyramidal 
tracts  extends  lower.  If  the  disease  mounts  higher,  it  passes  through  the 
medulla,  mainly  in  the  gray  matter  below  the  fourth  ventricle  and  the  pyramidal 
tracts  above  the  crossing,  and  may  proceed  through  the  internal  capsules  and 
peduncles  to  the  cortical  pyramidal  cells,  there  undergoing  a  cellular  degener- 
ation, similar  to  that  in  the  anterior  horns  of  the  cord.  The  pathologic  changes 
consist  in  a  simple  atrophy  of  the  muscular  fibers,  with  a  hyperplastic  growth 
of  the  perimysium,  either  primary  or  secondary  to  a  destructive  cord  lesion. 
Cord  changes  may  be  entirely  wanting  in  the  myopathic  form.  The  fibers  may 
undergo  fatty  degeneration  and  fat  or  the  sheaths  alone  remain.  There  are 
often  degenerated  nerve-fibers  in  the  nerve-trunks  which  can  be  traced  to  the 
anterior  horns. 


678  ORTHOPEDIC  SURGERY. 

Symptomatology. — The  invasion  is  always  gradual  and  insidious.  Some 
weakness  or  inability  to  use  the  affected  member  first  attracts  attention  to  the 
part,  which  is  usually  discovered  to  be  wasted  and  shrunken.  In  adults  the 
ball  of  the  thumb  or  the  shoulder  is  first  affected;  in  children  the  lumbar 
muscles,  and  later  the  leg  muscles  are  first  attacked. 

The  disease  may  be  .arrested  at  any  stage,  or  may  invade  other  muscles, 


Fig.  505.  Fig.  506.  Fig.  507. 

Figs.  505-507. — Peogkessive  Muscular  A«rophy.     Back,  Front,  and  Side  View  (Robert  Jones). 

tm  finally  every  voluntary  muscle  may  be  involved,  except  those  of  the  eyelids, 
eyeballs,  and  the  muscles  of  mastication,  a  condition  approaching  in  severe 
cases  absolute  helplessness.  The  atrophy  of  the  muscles  of  the  hands  gives 
rise  to  the  peculiar  "claw-hand"  characteristic  of  the  affection.  The  affected 
muscles  are  soft  and  flabby.  The  expression  is  vacant  and  idiotic,  from  palsy 
and  atrophy  of  the  facial  muscles,  producing  the  so-called  myopathic  face. 
The  affected  muscles  during  the  progress  of  the  disease  present  constant  fibrillary 


Fig.  50S. 


Fig.  509. 


Fig.  510. 


Fig.  511. 


Figs.  508-511.— progressive  muscular  atrophy,  showing  High  Degree  of  Scoliosis  .Stereo- 
scopic) (Lange). 


Fig.  512. 


Fig.  513. 


Fig.  314. 


Fig.  515. 


Figs.  512-515.— progressive  muscular  atrophy,  showing  High  degree  of  scoliosis  (Stereo- 
scopic) (Lange). 


OTHER  PARALYSES.  683 

contractions  visible  under  the  skin,  increased  on  exposure  to  cold.  Electric 
contractility  gradually  diminishes  with  the  waste  of  tissue.  Sensation  is  unim- 
paired unless  the  posterior  horns  are  affected,  when  pain  of  a  neuralgic  character 
is  experienced.  The  mind  remains  unaffected  to  the  end.  Death  is  due  to 
asphyxia  from  atrophy  of  the  diaphragm,  intercostals,  and  other  respiratory 
muscles. 

Progress  is  marked  by  repeated  pauses  extending  over  a  few  weeks  to  years, 
and  the  hereditary  primary  cases  and  those  due  to  ex-posure  to  cold  are  more 
decidedly  progressive  to  a  fatal  termination  than  those  due  to  over-exercise  of 
the  muscles.  The  muscles  of  the  bladder  and  rectum  and  the  heart  are  never 
implicated.  Permanent  contractions  result  in  talipes  equinus  and  equino- 
varus,  flexions,  lordosis,  and  scoliosis. 

Diagnosis. — The  affection  is  most  liable  to  be  mistaken  for  peripheral 
palsy  from  disease  or  injury  of  a  nerve,  chronic  lead-poisoning,  and  infantile 
paralysis. 

In  peripheral  palsy  the  history  of  injury,  the  sharply  localized  distribution, 
the  sudden  onset  of  paralyis  prior  to  atrophy,  and  the  impairment  of  sensation, 
would  distinguish  the  nerve  lesion. 

In  chronic  lead-poisoning  the  history,  symptoms,  distribution  of  the  palsy, 
and  mode  of  progress  will  generally  make  the  diagnosis  evident.  The  peripheral 
palsies  from  metallic  poisoning  will  be  most  difficult  of  recognition. 

In  infantile  paralysis  the  sudden  onset  of  the  paralysis  preceding  the  atrophy, 
the  loss  of  reflexes,  and  the  "reaction  of  degeneration"  are  all  of  service  in 
making  a  diagnosis. 

Prognosis. — The  prognosis  is  influenced  by  early  treatment,  but  when 
the  affection  becomes  generalized  it  grows,  as  a  rule,  progressively  worse.  The 
congenital  primary  cases  are  less  favorable  than  those  due  to  fatigue  from 
over-exercise,  since  the  former  are  liable  to  become  rapidly  generalized. 

Treatment. — The  general  health  requires  attention,  but  local  measures, 
especially  electricity,  offer  the  greatest  hope.  Strychnin  {iu  to  tV  of  the  nitrate) 
subcutaneously  has  been  of  great  benefit  in  these  cases.  The  continuous  and 
interrupted  currents  are  both  of  service;  the  more  marked  the  atrophy,  the 
more  intense  the  currents  and  the  more  rapid  the  interruptions.  Frictions  and 
massage  begun  early  and  continued  persistently  for  a  long  time  may  delay  the 
progress  of  the  affection,  and  diminish  the  severity  of  the  resulting  deformity. 
Vibratory  massage  is  of  some  value.  Tenotomy  should  be  employed  to  relieve 
deformities  produced  by  muscular  contractions.     When  the  atrophy  is  due  to 


684  ORTHOPEDIC  SURGERY. 

excessive  use,  rest  is  important.     This  last  statement  cannot  be  too  strongly 
emphasized. 

Hereditary  Ataxia. 

Hereditary  ataxia  is  a  chronic  degenerative  disease  of  the  posterior  and 
lateral  columns  of  the  cord,  characterized  by  serious  motor  disturbance, 
developed  during  childhood. 

Synonyms. — English,  Friedreich's  Ataxia;  Friedreich's  Disease;  Family 
Ataxia;   Generic  Ataxia;    Degenerative  Ataxia;  Hereditary  Ataxic  Paraplegia. 

Etiology. — The  disease  is  inherited  directly  or  indirectly,  there  being 
usually  a  family  history  of  neuroses.  Habitual  intemperance,  s}^hilis,  con- 
sanguinity, and  tuberculosis  and  other  cachectic  diseases  have  been  ascribed  as 
etiologic  factors.  Ataxia  is  rarely  directly  transmitted.  The  infectious  fevers, 
especially  scarlet  fever,  and  diphtheria,  dentition,  and  adolescence  are  usually 
the  exciting  causes.  The  disease,  as  in  all  other  familial-neurotic  diseases,  is 
more  usual  in  males,  and  it  is  mainly  transmitted  by  the  female  line.  In  a  fam- 
ily affected  by  this  disease,  the  onset  is  usually  progressively  early  in  succeeding 
children.  It  develops  in  infancy  and  childhood,  at  puberty,  and  in  early  adult 
life.     The  affection  is  comparatively  rare. 

Pathology. — There  are  two  forms,  the  cerebellar  and  spinal.  The  cere- 
bellar is  very  rare,  and  shows  cerebellar  atrophy,  said  not  to  be  sclerotic,  how- 
ever. There  are  unusual  thinness  of  the  gray  substance,  loss  and  degenera- 
tion of  Purkinje's  cells,  and  loss  of  white  matter.  The  whole  organ  may  be 
one-half  or  two-thirds  smaller  than  usual.  In  these  cases  there  seems  to  be  no 
cord  involvement.  The  spinal  lesion  is  similar  to  that  of  locomotor  ataxia^ 
a  primary  degeneration  of  the  lateral  columns  with  degenerative  atrophy  and 
sclerosis  of  the  posterior  columns.  It  commences  in  the  lumbar  region,  and 
extends  upward  and  downward,  involving  finally  the  medulla,  and  particularly 
the  origin  of  the  hypoglossal  nerve.  According  to  Marie,  the  upper  motor 
neurons  are  not  directly  affected,  the  fibers  affected  in  the  p}Tamidal  tracts 
being  those  relating  to  the  direct  cerebellar  tracts  and  Gowers'  tract,  being  those 
portions  of  the  cord  last  developed.  The  cord  is  usually  small,  presenting  only 
two-thirds  of  its  normal  size.  The  difference  is  clinical  and  etiologic  rather 
than  pathologic. 

Symptomatology. — The  earliest  symptoms  are  weakness  and  uncertainty 
in  walking,  with  slight  numbness  and  pain  in  the  lower  extremities.  The 
motions  of  the  legs  are  improperly  co-ordinated.     Irregular  jerkings  of  the 


OTHER  PARALYSES. 


685 


head  and  neck  are  seen.  Headache,  vertigo,  and  impairment  of  speech,  and 
nystagmus  are  often  present. 

The  patellar  reflex  is  early  lost;  trophic  disturbances  are  slight;  the 
sphincters  are,  as  a  rule,  unaffected;  cutaneous  anesthesia  is  usually  absent. 
Incoordinate  or  choreiform  movements  may  develop  in  the  extremities. 

Deformities  occur  in  the  later  stages — talipes  varus  or  ec^uinovarus,  hyper- 


FiG.  516. — Spina  Bifida  in  a  Giel  of  Twelve  Years 
(Lange). 


Fig.  517. — Same,  Later.'\l  View. 


extension  of  the  toes,  permanent  flexion  of  the  knees,  and  lateral  curvature 
of  the  spine. 

Diagnosis. — The  distinguishing  characteristics  are  the  development  early 
in  life  of  ataxia,  paraplegic  in  character,  with  loss  of  reflexes,  disturbances  of 
speech,  and  deformities,  without  cutaneous  anesthesia,  acute  pain,  or  paralysis 
of  sphincters,  but  with  hereditary  or  family  history  of  neuroses.  The  absence  of 
the  Argyll-Robertson  pupil  distinguishes  hereditary  ataxia  from  locomotor  ataxia. 


686  ORTHOPEDIC  SURGERY. 

Prognosis. — The  disease  is  progressively  fatal,  death  usually  occurring 
from  some  intercurrent  affection,  the  average  duration  of  the  disease  being 
fifteen  or  twenty  years. 

Treatment. — Improved  hygiene  with  persistent  regular  massage  is  of  the 
greatest  service.  Suspension,  as  in  locomotor  ataxia,  should  be  tried,  and 
cases  are  recorded  in  which  it  proved  beneficial.  The  infectious  diseases  of 
childhood,  especially  scarlet  fever  and  diphtheria,  should  be  especially  avoided, 
and  injury  by  blows  or  falls  should  be  guarded  against. 

Electricity  may  be  employed  to  maintain  the  nutrition.  Tonics,  especially 
arsenic,  are  sometimes  of  temporary  benefit.  The  animal  extracts  may  be 
tried.  Flat-foot,  club-foot,  and  lateral  curvature  require  the  appropriate 
treatment  described  in  the  other  sections. 

Peripheral  Palsies. 

1.  Spina  Bifida  Paralysis. — The  deformity  and  paralysis  associated  with 
spina  bifida  are  sufiiciently  common  to  deserve  consideration  here.  The  paralysis 
is  most  common  in  the  sessUe  variety,  and  is  accompanied  by  an  impairment 
of  motor  power  in  the  entire  lower  extremities  with  contraction  of  the  extensor 
longus  digitorum  and  hamstring  tendons.  The  patient  walks  with  knees  flexed 
and  the  feet  in  a  position  of  valgus. 

The  treatment  consists  in  dividing  the  tendons  of  the  contracted  muscles 
and  the  use  of  paralytic  leg  braces  with  pads  at  the  inner  side  of  the  knee 
and  ankle. 

2.  Pressure  Palsies. — These  result  from  pressure  upon  nerve-trunks 
by  causes  operating  both  within  and  without  the  body,  such  as  by  tumors, 
aneurysms,  foreign  bodies,  excessive  bone  caUus,  the  use  of  crutches,  or  as  the 
result  of  certain  avocations  or  professions. 

The  symptoms  resemble  those  of  infantile  spinal  palsy.  The  prognosis 
is  good  if  the  cause  can  be  removed.  The  treatment  consists  in  removal  of  the 
cause  in  so  far  as  possible,  followed  by  electricity,  massage,  and  vibration. 
Neuroplasty  has  been  successfully  employed  in  cases  where  the  nerve  has  been 
completely  included  in  callus. 


CHAPTER  XXI. 
TORTICOLLIS. 

Torticollis  is  a  distortion  of  the  neck,  constant  or  intermittent  in  character, 
in  which  the  head  is  drawn  aAvry. 

Synonyms. — English,  Wry-neck;  Caput  Obstipum;  CoUum  Distortum. 
French,  Cou  Tortu;  Coutors.  German,  Schiefhals.  Italian,  Torticolli. 
Spanish,  Torticollis. 

Frequency, — According  to  some  writers,  the  sexes  are  about  equally 
affected;  but  according  to  others,  males  are  more  frequently  affected  than 
females;  and  according  to  others,  females  are  more  frequently  affected  than 
males.  Thus,  in  444  cases  collected  by  Whitman,  246  were  females  and  198 
were  males.  The  right  side  was  formerly  thought  to  be  more  liable  than  the 
left,  as  seen  by  the  37  cases  collected  by  Dieffenbach,  in  which  5  only  were 
on  the  left  side,  and  in  29  cases  recorded  by  Bouvier,  18  were  on  the  right  side. 
But,  on  the  other  hand.  Whitman's  figures  seem  to  show  a  greater  frequency 
of  torticollis  on  the  left  side,  for  of  the  444  cases  recorded  by  him  in  432  of  which 
the  affected  side  was  mentioned,  196  were  on  the  right  and  236  were  upon  the 
left  side. 

Etiology. — ^Wry-neck  is  both  congenital  and  acquired,  the  latter  being 
much  more  common  than  the  former. 

Congenital. — Cases  are  recorded  of  wry-neck  in  a  stillborn  infant,  and 
a  case  of  unilateral  atrophy  of  the  head,  but  the  majority  of  so-called  congenital 
cases  occur  at  birth  from  injury.  In  the  true  congenital  variety  the  wry-neck 
is  caused  by  a  malposition  of  the  fetal  head  in  the  maternal  pelvis,  producing 
permanent  shortening  of  the  relaxed  muscles.  This  may  be  favored  by 
deficiency  of  liquor  amnii,  by  abnormal  pressure  of  the  uterus,  or  possibly, 
as  Petersen  suggests,  may  result  from  an  attachment  between  the  skin  of  the 
face  and  the  amnion  in  early  embryologic  life. 

A  lateral  deficiency  of  the  cervical  vertebras  may  also,  though  more  rarely, 
cause  it.  The  fact  that  congenital  torticohis  aft'ects,  as  a  rule,  the  right  side 
is  easily  explained  by  the  great  predominance  of  the  left  occipital  anterior 
position  of  the  fetus,  since  in  this  position  the  fetal  head  lies  in  the  pelvis  in  a 

6S7 


6SS 


ORTHOPEDIC  SURGERY. 


position  of  flexion  toward  the  right  shoulder,  and  this  position,  if  extreme  or 
long  continued,  will  produce  a  shortening  of  the  right  sternomastoid,  the  muscle 
most  frequently  affected.  In  such  cases  the  deformity  may  not  be  altogether 
muscular,  but  may  extend  to  and  involve  the  skull  and  cervical  spine.  In 
congenital  cases  heredity  appears  to  play  a  role,  as  shown  by  numerous  recorded 
cases.  The  frequent  association  with  other  deformity  in  congenital  cases 
points  to  malposition  in  iitero  as  a  cause.     I  am  convinced  that  numerous  cases 

of  congenital  wry-neck  may  be  traced 
to  prenatal  nervous  lesions,  either 
central  or  peripheral. 

Acquired. — The  acquired  form 
includes  several  varieties,  which  may 
be  grouped  into  rheumatic,  trauma- 
tic, tetanoid,  paralytic,  compensa- 
tory, cicatricial,  and  idiopathic. 

Rheumatic  torticollis  is  a  very 
common  affection  seen  in  persons 
who  have  inherited  the  rheumatic 
diathesis  or  who  have  acquired 
lithemia. 

Traumatic  cases  result  from 
blows,  twists  of  the  neck,  rupture  of 
the  sternomastoid  muscle,  and  from 
violence  received  during  forceps  de- 
livery, pressure,  or  the  manipulations 
of  the  accoucheur.  Rupture  of  the 
muscular  fibers,  particularly  of  the 
sternomastoid,  is  produced  with  sub- 
sequent induration  and  cicatricial  contraction  of  the  muscle.  This  rupture  may 
occur  in  a  muscle  shortened  in  ntero.  Hematoma  of  the  muscles  is  often  present, 
but  its  relation  to  wry-neck  is  at  present  undetermined.  According  to  Stromeyer's 
theory,  congenital  torticollis  is  caused  by  rupture  of  the  muscle  producing  a  myo- 
sitis and  hematoma  which  goes  on  to  fibrous  induration  and  consequent  contrac- 
tion of  the  muscle.  But  this  theory  is  now  discarded,  since  the  association  between 
hematomas  and  torticollis  is  by  no  means  constant.  Petersen  believes  hematoma 
is  found  in  already  existing  torticollis,  Fassbender  has  observed  it  upon  the  side 
opposite  to  the  wry-neck,  and  the  experiments  of  Witzel  aad  Fabry  upon  rabbits 


IMG.     51S.- 


-Defoeited    Skull    from    Torticollis 
(Joachimsthal). 


TORTICOLLIS. 


689 


failed  to  prove  that  hematomas  produce  torticolHs.  Petersen  vigorously  combats 
the  theory  of  Stromeyer,  Weiss  flatly  denies  it,  but  personally  I  believe  that  the 
majority  of  causes  of  congenital 
torticollis  operate  before  rather  than 
during  delivery.  In  rare  cases  frac- 
ture and  dislocation  of  the  cervical 
vertebras  have  been  observed  as 
causes. 

Tetanoid  or  spastic  contraction 
of  the  muscles  of  the  neck,  either 
tonic  or  clonic,  results  from  a  cen- 
tral lesion;  from  a  peripheral  irri- 
tation, as  from  inflammatory  con- 
ditions of  the  bones,  ligaments,  or 
muscles;  or  as  a  local  manifesta- 
tion of  some  central  or  spinal  irri- 
tation. Choreiform  spasm  sometimes  occurs, 
common  cause  of  acquired  torticollis. 


Fig.  51Q. — Right  Dorsal  Scoliosis  in  Muscular 
Subject,  Secondary  to  Torticollis. 


Peripheral    irritation   is    & 


Fig.  520.  Fig.  521. 

Figs.  520,  521. — Ocular  Torticollis  from  Hypermetropic  Astigmatism  (Joachimsthal). 


Paralytic  v\^ry-neck  may  arise  from  unilateral  muscular  action  in  paralysis 
of  the  other  side,  either  peripheral  or  central  in  origin. 


690  ORTHOPEDIC  SURGERY. 

Compensatory  torticollis  is  met  in  lateral  curvature,  but  in  many  instances 
of  association  of  these  two  conditions,  the  wry-neck  will  be  found  to  be  primary. 
Of  a  compensatory  nature  also  are  those  cases  of  wry-neck  developed  from 
unilateral  loss  of  vision,  inequality  of  visual  acuity,  or  a  diiierence  in  the 
plane  of  vision  of  the  two  eyes — amaurosis,  astigmatism,  or  h3^erphoria.  This 
condition  has  been  termed  by  Quignet,  torticollis  oculaire — a  not  infrequent 
condition  in  the  writer's  experience. 

Cicatricial  wry-neck  results  from  extensive  burns  and  scalds,  abscesses, 
cicatrices  from  suppurating  cervical  glands,  or  lupus  of  the  neck. 

Idiopathic  cases  occur  in  which  no  definite  lesion  is  discoverable,  but  in 
which  general  nervous  debility  has  developed  a  local  spasm  as  a  result  of  some 
emotional  cause,  such  as  grief,  fright,  etc. ;  or  as  an  accompaniment  of  hysteria. 
Among  other  causes  may  be  mentioned  tumors  of  the  sternocleidomastoid 
muscle — sarcomatous,  fibrous,  or  syphilitic.  The  long-continued  holding  of  the 
head  in  a  strained  position  may  produce  a  torticollis,  as  seen  in  certain  occupa- 
tions, or  the  condition  may  result  from  carrying  heavy  burdens  on  one  shoulder. 
Pathology. — In  the  traumatic  cases  occurring  at  birth,  the  patholog}' 
consists  of  a  laceration  of  the  sternomastoid  muscle  from  torsion  of  the  neck, 
followed  by  hemorrhage,  succeeded  later  by  an  encapsulating  inflammation 
and  a  fibrous  induration  and  shortening  of  the  muscle,  in  severe  cases  the  entire 
muscle  being  converted  into  a  fibrous  band.  In  the  chronic  forms  alterations 
occur  in  the  muscles,  fascias,  ligaments,  and  bones  from  malposition  or  disuse. 
The  muscles  most  frequently  involved  are  the  sternocleidomastoid,  trapezius, 
splenius,  scaleni,  rarely  the  complexus,  and  the  platysma,  although  in  severe  cases 
all  the  muscles  of  the  neck  participate.  This  affection  involves  the  distribution 
of  the  spinal  accessory  nerve,  and  is  usually  due  to  central  disease,  lesion  of 
this  nerve,  or  disease  of  the  muscles  themselves.  The  affected  muscles  undergo 
fibrous  degeneration,  becoming  hard  and  unyielding.  The  contraction  continu- 
ing, anatomic  changes  are  produced  which  not  only  tend  to  fix  the  cervical 
vertebras  in  their  deformed  relations  but  also  to  exaggerate  the  abnormal  curves 
and  produce  other  compensatory  curves.  These  changes  are  chiefly  atrophy 
of  the  bones  and  intervertebral  cartilages  on  the  concave  side  of  the  curve, 
with  shortening  of  the  ligaments  and  muscles,  and  hypertrophy  of  the  bone 
and  cartilage,  with  elongation  of  the  ligaments  and  thickening  of  the  muscles 
on  the  other  side.  Asymmetry  of  the  face  has  been  ascribed  to  gravitation 
of  the  blood  to  the  more  dependent  side;  to  muscular  tension;  to  pressure  and 
retarded  development  of  the  vessels  and  nerves  on  the  side  of  the  concavity; 


TORTICOLLIS.  691 

to  tension  of  the  soft  parts,  particularly  the  muscles  of  the  sound  side;  and  to 
interference  with  function.  Atrophy  of  the  affected  side  and  asymmetry  of 
the  skull  have  been  variously  ascribed  by  different  authors  to  deficient  activity 
of  the  muscles  of  inspiration  on  the  affected  side,  as  in  ordinary  scoliosis;  to 
the  constant  pull  of  the  contracted  sternomastoid  muscles;  to  faulty  nutrition 
on  account  of  compression  of  the  carotid  artery  and  other  great  vessels  of  the 
neck  on  the  affected  side  (Bouvier);  to  interference  with  the  function  of  the 
part,  causing  atrophy  from  disuse,  as  in  asymmetry  of  the  face ;  to  hyperextension 
of  the  muscles  on  the  sound  side;  and  to  the  misplacement  of  the  epiphysis 
of  the  basilar  portion  of  the  occipital  bone,  and  the  effect  of  the  weight  of  the 
skull  upon  the  other  cranial  and  facial  bones  (Nicoladoni) .  Of  these  the 
theory  of  Bouvier  perhaps  best  explains  the  atrophy,  and  that  of  Nicoladoni 
the  asymmetry  of  the  skull  and  also  the  osseous  changes  in  the  face.  The 
sternal  head  of  the  sternocleidomastoid  is  more  frequently  affected  than 
the  clavicular  head,  the  clavicular  head  being  rarely  involved,  but  when  involved 
it  is  always  associated  with  an  involvement  of  the  sternal  head. 

Symptomatology. — The  affection  may  be  acute  or  chronic,  constant 
or  intermittent.  In  the  acute  form  the  onset  is  usually  sudden,  often  succeeding 
a  sudden  violent  movement  or  effort.  There  is  pain  on  motion,  with  tenderness 
of  the  affected  muscles,  and  the  head  is  held  awry.  The  aft'ected  muscle  is 
tense  and  stands  out  prominently  from  beneath  the  skin.  Its  response  to  electric 
stimulus  is  diminished.  The  acute  form  may  become  chronic.  The  position 
of  the  head  varies  with  the  muscles  aft'ected.  In  the  most  common  variety, 
in  which  the  sternocleidomastoid  muscle  is  affected,  the  head  is  drawn  to  one 
side,  the  face  being  rotated  in  an  opposite  and  somewhat  upward  direction 
and  in  severe  cases  the  face  may  look  directly  to  the  sound  shoulder  and  the 
neck  on  the  affected  side  be  buried  out  of  sight.  The  malposition  of  the  head 
cannot  be  forcibly  corrected,  and  attempts  to  do  so  cause  pain.  Asymmetry 
of  the  face,  the  oblique  position  of  the  nose,  the  irregularity  of  the  eyes  and 
commissures  of  the  lips,  the  diminished  size  of  the  features  on  the  affected  side> 
are  peculiar  and  characteristic.  Asymmetry  of  the  face  is  rarely  lacking,  whether 
the  wry-neck  be  congenital  or  acquired.  Marked  atrophy  of  the  affected  side 
and  asymmetry  of  the  skull  are  present  in  severe  grades  of  the  aff'ection.  In 
severe  cases  the  jaw  is  frequently  rotated  so  that  the  teeth  cannot  be  approxi- 
mated. In  chronic  cases  a  compensatory  lateral  curvature  of  the  spine  results 
from  the  curvature.  Intermittent  torticollis,  either  unilateral  or  bUateral, 
is  essentially  a  nervous  aft'ection  occurring  in  later  life,  and  is  often  choreiform. 


692  ORTHOPEDIC  SURGERY. 

Convulsive  contractions  vary  from  an  occasional  jerk  to  an  almost  constant 
spasm.  It  is  more  frequent  in  females,  is  usually  clonic,  but  may  become 
tonic,  and  is  often  painful.  When  unilateral  it  constitutes  the  so-called  tic 
giratoire  of  Trousseau.  Another  variety,  described  as  occipito-atloidean, 
consists  of  a  subluxation  of  the  atlas  on  the  occipital  bone,  producing  a  twisting 
of  the  head  which  resembles  torticollis,  and  which  is  a  bony  ankylosis,  a 
rheumatic  sequel. 

Diagnosis. — While  there  is  little  difficulty  in  recognizing  the  deformity 
itself,  it  is  most  important  to  distinguish  it  from,  other  conditions,  such  as  cervical 
caries,  simple  cervical  abscess  and  cervical  adenitis,  in  which  the  head  is  held 
awry  without  muscular  spasm  or  contraction.     The  diagnosis  as  to  which 
muscles  are  affected  is  made  by  palpation,  when  the  contracted  or  retracted 
muscle  may  readily  be  felt  as  a  tense  prominent  band  under  the  skin.     Ordinary 
stiff-neck  from  cold  may  at  all  times  be  easily  distinguished  by  the  history  of 
exposure  to  cold,  by  the  transitory,  shifting,  and  less  severe  character  of  the 
affection,  the  pain  and  tenderness  on  pressure.     Cervical   caries  can  usually 
be  distinguished  by  the  greater  rigidity,  by  more  severe  pain  and  its  persistence 
even  when  the  patient  is  recumbent,  by  dysphagia,  the  attitude  of  the  patient, 
supporting  the  head  with  the  hands,  the  facial  expression  of  pain,  and  the 
coexistence  of  tubercular  diathesis  or  lesions  elsewhere.     In  anterior  torticollis 
due  to  caries,  the  sternomastoid  is  not  so  permanently  nor  so    prominently 
contracted.     In  posterior  torticollis  due  to  caries  the  symptoms  are  almost 
identical  with  those  of  posterior  idiopathic  torticollis,  but  the  fact  that  in  spinal 
caries  the  head  is  rotated  toward  the  contracted  muscle,  whereas  in  idiopathic 
cases  of  wry-neck  the  rotation  takes  place  away  from  it,  is  of  the  greatest  diag- 
nostic value.     Again,  in  spinal  caries  all  movements  of  the  neck  are  resisted 
and  attended  with  pain,  whereas  in  wry-neck  the  movements  are  freer  and  only 
certain  muscles  are  firmly  contracted,  the  rest  being  relaxed.     The  greatest 
importance  attaches  to  the  differential  diagnosis  between  posterior  idiopathic 
torticollis  and  torticollis  due  to  cervical  caries,  since  the  writer  has  had  related 
to  him  a  case  where  an  attempt  forcibly  to  straighten  a  case  of  torticoHis  due 
to  cervical  caries  resulted  in  instant  death.     In  simple  cervical  abscess  the 
symptoms  are  those    of   acute   local   inflammation,    superficial    in    character 
and  attended  with  fever,  and  in  cervical  adenitis  there  is  circumscribed,  deep- 
seated  inflammation,  without  characteristic  muscular  spasm.     The  paralytic 
form  may  be  recognized  by  the  unsupported  head  falling  away  from  instead 
of  toward  the  affected  side,  by  the  abUity  to  correct  the  deformity  but  the 


TORTICOLLIS. 


693 


immediate  return  of  the  head  to  its  deformed  position  as  soon  as  the  corrective 
force  is  removed,  and  by  evidences  of  paralysis  elsewhere.  However,  it  must 
be  remembered  that  if  the  paralytic  torticollis  be  of  long  standing,  the  muscles 
on  the  unaffected  (nonparalyzed)  side  may  become  atrophied  and  permanently 
retracted  instead  of  simply  relaxed,  and  the  head  would  then  be  held  in  a  position 
away  from  the  paralyzed  side,  and  any  attempt  to  correct  the  malposition  would 
be  resisted  and  rendered  impossible  by  the  contracted  muscle. 


Fig.  522. — Right  Dorsal  Scoliosis.     Inequality 
in  scapul.e  and  hips,  showing  tosticollis. 


Fig. 


-Same,  Side  View. 


Prognosis. — Acute  idiopathic  muscular  torticollis  tends  rapidly  toward 
recovery,  but  may  become  chronic.  Wry-neck  due  to  peripheral  irritation 
terminates  usually  upon  removal  of  the  cause.  Paralytic  cases  require  time  and 
the  recourse  to  mechanical  appliances.  Traumatic  cases,  the  so-called  congenital 
cases,  and  the  ordinary  chronic  acquired  affection  are  entirely  curable  by  surgical 
means.  The  deaths  reported  following  operation  for  torticollis  have  been  due 
to  hemorrhage,  septicemia,  and  injury  to  the  pleura.  The  intermittent  form 
may  cease  spontaneously,   but  usually  remains  unchanged  for  years,  unless 


694 


ORTHOPEDIC  SUR3ERY 


subjected  to  surgical   interference,  when  encouraging  success  usually  follows 
radical  operation. 

Treatment. — The   treatment   will    depend   upon   the   variety,   and   may 
be  divided  into  therapeutic,  mechanical,  and  operative. 

Therapeutic.     In  acute  inflammatory  forms  much  benefit  will  be  obtained 

by  the  correction  of  the  coincident  constitutional  disturbance.    A  gentle  purge, 

followed  by  salicylate  of  soda,  with  the  local  application  of  warmth,  the  oleate 

of  morphin,  or  atropin,  injected  directly  into  the  belly  of  the  contracted  muscle, 

will  be  all  that  is  required.     Much   comfort   may  be 

obtained  in  very  painful  cases  by  supporting  the  head 

by  means  of  a  high  pasteboard  collar  bandaged  firmly 

around  the  neck,  in  addition  to  the  hot  applications. 


Fir,.  524. — LoRENZ   Bandage 
FOR  Torticollis  (Hoffa). 


Fig.  525. — Plaster  Cravat  for  Torticollis  (Joachimsthal). 


etc.  In  paralytic  cases  the  endermic  use  of  strj'chnin  is  recommended.  Verneuil 
recommends  pulverizations  of  ether  as  being  most  efficient.  'When  dependent 
upon  general  debility,  the  health  should  be  restored  by  means  of  tonics,  massage, 
improved  hygiene,  and  general  bathing.  When  dependent  upon  ocular  defect, 
the  insufficiency  should  be  corrected  with  prisms,  tenotomy  being  performed  only 
when  the  insufficiency  amounts  to  twelve  degrees  or  over.  In  a  case  of  the  writer's 
a  one  degree  prism,  base  down,  in  the  left  eye  corrected  the  insufficiency,  and, 
with  the  proper  correction  for  hypermetropia,  relieved  the  torticollis.     Electricity 


TORTICOLLIS. 


695 


is  of  value  and  is  often  followed  by  cure.  Gelsemium  (fluid  extract)  in  physi- 
ologic or  hyper-physiologic  doses,  as  suggested  by  Weir  Mitchell,  may  be 
employed  after  failure  to  relieve  the  muscular  spasm  by  galvanism  or  before 
resorting  to  nerve  resection.  In  intermittent  cases  the  actual  cautery  to  the 
back  of  the  neck  is  recommended.  In  chronic  cases  of  posterior  torticollis 
forcible  straightening  under  an  anesthetic  without  tenotomy  has  been  success- 
fully employed  by  Delore.  In  these  obstinate  cases  tenotomy  of  the  deeper 
posterior  muscles  is  impossible.  The  method  of  Delore  consists  in  anesthetizing 
the  patient,  and  while  an  assistant  firmly  holds  the  shoulders,  the  surgeon 
grasps  the  head  firmly  with  both  hands  and  gradually  but  forcibly  rotates  it 
in  all  directions.  When  the  deformity  is  overcome, 
the  head,  neck,  shoulders,  and  trunk  are  fixed  in  an 
over-corrected  position  by  a  plaster-of-Paris  bandage. 
A  positive  diagnosis  of  posterior  torticollis  from  caries 
of  the  cervical  vertebras  must  be  made  before  resorting 
to  this  plan  of  treatment. 

Mechanical.  Mechanical  appliances  without 
operation  are  unsatisfactory,  except  in  paralytic  cases. 
In  these,  after  the  therapeutic  means  have  failed  to 
recall  the  lost  muscular  power,  mechanical  apparatus 
is  useful.  The  mechanical  principle  involved  is  to  ob- 
tain fixation  on  the  trunk,  from  which  counter-pressure 
is  made  upon  the  head.  After  its  application  the  appa- 
ratus should  be  worn  from  three  to  five  months,  when 
it  may  be  permanently  discarded. 

The  mechanical  appliances  used  to  retain  the  head  in  its  correct  position 
after  operation  are  both  numerous  and  varied.  A  simple  and  most  efficient 
form  of  appliance  consists  of  a  broad  adhesive  strip  around  the  forehead  and 
occiput,  and  another  around  the  waist,  fastening  the  two  together  by  means 
of  a  bandage  or  rubber  band  carried  from  above  the  ear  of  the  unaffected  side 
across  the  chest  to  the  opposite  side  of  the  trunk. 

After  operation  the  head  may  be  secured  in  a  slightly  over-corrected 
position  by  incasing  the  head^  neck,  and  shoulders  in  a  plaster-of-Paris  cast. 

More  elaborate  appliances  are  needed  to  twist  the  head,  and  these  are 
all  constructed  upon  the  principle  of  that  of  Jorg.  Of  these  a  great  variety 
exist,  and  are  well  illustrated  in  the  chin-rest  used  in  the  treatment  of  cervical 
cases  and  in  the  accompanying  illustrations  of  that  of  Sayre,    recommended 


Fig.  526. — Sayre's  Brace  for 
Torticollis. 


696 


ORTHOPEDIC  SURGERY. 


by  the  writer.  The  apparatus  of  Sayre  consists  of  two  upright  malleable  steel 
bars  which  pass  up  the  back  on  either  side  of  'the  spine  and  curve  over  the 
shoulders,  on  which  they  rest.  Below,  they  are  attached  to  a  band  passing 
around  the  pelvis.  The  head-piece  is  supported  upon  a  rod  by  a  universal 
joint  attached  by  means  of  a  similar  universal  joint  to  the  spinal  uprights  at 
a  point  corresponding  to  the  first  dorsal  vertebra,  or,  what  is  perferred,  by 
three  Archimedean  screws,  since  the  former  requires  two  persons  for  a  proper 
adjustment.  This  rod  has  a  ratchet  and  key  movement  for  elongation.  The 
head-piece,  a  padded  piece  of  malleable  steel,  runs  from  the  base  of  the  skull 


Fig.  527. — Torticollis  bepoee  Tenotomy  of  the 
Sternomastoid  Muscle  (Joachimsthal). 


Fig.  S28. — Same,  after  Operation. 


forward  and  upward,  curving  over  each  ear.  From  the  ends  of  the  metal 
head-piece  a  leather  strap,  made  adjustable  by  a  buckle,  passes  across  the 
forehead,  and,  by  means  of  hooks,  a  strap  is  attached  which  passes  under  the 
chin. 

Collars  of  pasteboard,  felt,  leather,  and  wire,  sometimes  spoken  of  as 
Minerva  collars  {collier  Minerve),  from  the  simplest  to  the  most  elaborate 
forms,  are  employed  to  fix  the  distorted  head,  but  these  are  most  efficient  after 
operation. 

Operative  treatment.  Tlije  operative  procedures  employed  are  tenotomy, 
nerve-stretching,  nerve-division,  and  nerve-resection. 


TORTICOLLIS. 


697 


Tenotomy  of  the  sternomastoid  is  most  frequently  required,  and  this  may 
be  performed  subcutaneously  or  by  open  incision.  For  the  technic  the 
reader  is  referred  to  Part  I. 

The  post-operative  treatment  consists  in  securing  the  head  in  an  over- 
corrected  position,  by  plaster  dressing  or  other  mechan- 
ical means,  for  from  ten  to  fourteen  days,  when  the 
after-treatment  should  be  begun.  This  orthopedic 
treatment,  which  is  the  most  important  and  upon  which 
the  success  of  operation  depends,  consists  in  massage 
of  all  the  muscles  of  the  neck  and  the  gradual  but  forci- 
ble manipulation  of  the  head  in  such  a  manner  as  to 
stretch  the  formerly  shortened  muscles  and  to  strengthen 
the  weaker  muscles. 

If  the  patient  is  afiflicted  with  posterior  torticollis  . 
with  inclination  of  the  head  toward  the  left  shoulder 
and  the  chin  rotated  to  the  right,  certain  special  exer- 
cises are  necessary,  and  these  should  be  given  by  the 
surgeon  himself  or  should  be   entrusted  to  a  skilled 


^^ 


Fig.  529. — Manual  Coeeection  for  Torticollis  (Hoffa). 


Fig.  530. — Suspension  Cor- 
rection FOR  Torticollis 
(Hoffa). 


gymnast.  The  following  exercise  has  been  found  of  great  value:  the  patient  is 
seated  upon  the  plinth  with  the  feet  fixed  in  the  stkrups  and  the  thighs  secured 
with  a  strap.  The  surgeon  or  gymnast  stands  behind  the  patient  and  seizes  the 
left  lower  jaw  of  the  patient  with  his  left  hand,  and  with  the  other  hand  on  the 
right  side  of  the  patient's  head,  rotates   the  head  toward  the  right.     In  this 


698  ORTHOPEDIC  SURGERY. 

manner  the  movements  of  the  head  are  under  the  perfect  control  of  the  sur- 
geon and  the  correct  position  is  secured  and  maintained  for  a  time.  One 
treatment  may  be  followed  by  a  cure. 

In  small  children  the  patient  may  be  placed  betweent  the  knees  of  the  sur- 
geon and  the  head  may  be  gently  but  firmly  corrected  from  behind. 

A  very  useful  exercise  is  one  which  can  be  given  in  the  Weigel-Hoffa  lateral 
curvature  machine.  The  head  extension  is  so  arranged  that  the  straps  are 
shorter  on  the  side  of  the  deformity.  When  the  head  is  extended,  the  deformity 
is  corrected. 

A  home  exercise  may  be  given  consisting  of  the  patient  sv/inging  in  an 
extension  head-gear,  the  cord  of  which  is  not  attached  to  the  center  of  the  bar 
but  on  the  bar  toward  the  side  of  the  contracted  muscles.  A  weight  should 
be  held  in  the  hand  of  the  affected  side. 

Nerve  Operations.  In  intermittent  torticollis  resection  of  the  spinal 
accessory  nerve  has  been  successfully  employed.  The  technic  has  already 
been  given  in  Part  I,  to  which  the  reader  is  again  referred. 

In  obstinate  cases  resection  of  the  posterior  roots  of  the  upper  cervical 
nerves  has  been  successfully  performed.  This  is  a  very  difficult  operation, 
and  one  which  will  test  the  dexterity  of  the  most  skilful  surgeon.  The  nerve- 
supply  of  the  posterior  rotators,  the  rectus  capitis,  splenius  capitis,  posticus 
major,  and  obliquus  inferior,  must  be  paralyzed. 

The  operation  as  described  by  Keen*  is  a  very  efficient  one.  At  the  level 
of  a  point  one-half  inch  below  the  lobule  of  the  ear  a  transverse  incision  is  made 
beginning  posteriorly  at  the  mid-line  of  the  neck  and  running  fora^ard  for  two 
and  a  half  inches.  The  trapezius  and  complexus  are  divided  transversely, 
carefully  avoiding  the  great  occipital  nerve.  The  posterior  branch  of  the  second 
occipital  nerve  is  resected.  The  suboccipital  nerve  is  exposed  in  the  suboccipital 
triangle.  It  is  followed  down  and  divided  close  to  the  spine.  Just  below  the  great 
occipital  nerve  the  common  trunk  of  the  two  roots  is  exposed  and  divided  close 
to  the  bifurcation  of  the  nerve-trunk.  The  nerve-supply  of  the  affected  muscles 
is  thus  removed,  causing  a  paralysis  and  consequent  relaxation  of  these  muscles. 

Richardson  and  Walton  produced  very  satisfactory  results  by  simply 
resecting  the  nerves  which  supplied  the  affected  muscle,  combining  this  with 
myotomy  if  the  contraction  was  permanent. 

*"  Annals  of  Surgery,"  January,   1891. 


CHAPTER  XXII. 
NEUROMIMESIS. 

Neuromimesis  includes  certain  functional  or  mimicked  affections  associated 
with  the  hysteric  diathesis. 

Synonyms. — These  affections  have  been  variously  recognized  as  simple 
hysteria;  as  Gelenknenrose;  as  the  mimicry  of  disease;  and  as  hysteric  joint 
affections.     Italian,  Isteria  mimetica,  Neuromimesi.     Spanish,  Neuromimesis. 

Frequency. 

The  frequency  with  which  joint  diseases  are  mimicked  is  very  great.  The 
assertion  may  be  made  and  fully  indorsed  by  the  experience  of  competent 
observers  that  four-fifths  of  the  female  patients  in  the  upper  classes  of  society 
who  are  supposed  to  have  joint  disease  have  hysteria  and  nothing  else.  It 
is  frequently  encountered  among  the  lower  classes  also. 

There  is  no  type  or  form  of  organic  paralysis,  no  contracture  or  spasm, 
and  no  articular  deformity  depending  upon  chronic  inflammation  or  disturbed 
muscular  action,  which  may  not  be  simulated  in  hysteria.  The  knee,  hip, 
spine,  and  ankle  are  most  frequently  affected  in  the  order  named. 

Etiology. 

These  affections  are  most  common  in  women  of  a  pronounced  brunet  type, 
and  usually  appear  about  the  time  of  puberty  or  young  womanhood.  The 
manifestations  may  continue  untU  the  menopause  or  even  later,  and  are  often 
associated  with  ovarian  or  uterine  disorders.  Men  and  boys  are  not  exempt. 
Debility,  HI  health,  and  neurasthenia  are  often  associated.  Heredity  and 
education  are  the  most  important  predisposing  causes.  Errors  of  refraction 
are  sometimes  the  starting-point  of  a  hysteric  explosion.  Traumatism  is  often 
an  exciting  cause.  Real  disease  is  often  present,  but  the  symptoms  are  all 
exaggerated,  and  hysteria  is  imposed  upon  an  original  organic  pathologic  con- 
dition. The  etiology,  in  fact,  differs  but  little  from  the  etiology  of  hysteria 
in  general.  The  local  manifestation  is  engrafted  upon  a  state  in  which  ideas 
control  the  body  and  produce  morbid  changes  in  its  functions. 


700  ORTHOPEDIC  SURGERY. 

Symptoms . 

These  include  three  groups — the  paralyses,  spastic  contractions,  and  joint 
disease. 

Paralyses. — These  vary  from  slight  transitory  loss  of  power,  which  can 
hardly  be  termed  palsy,  to  severe  cases  of  long  standing,  which  may  be  readily 
mistaken  for  lateral  sclerosis,  as  in  the  case  which  Osier,  in  1879,  frequently 
showed  at  the  Montreal  General  Hospital  as  a  typical  example  of  lateral  sclerosis, 
and  which  after  persisting  for  eighteen  months  disappeared  completely.  In 
form  they  may  be  hemiplegic,  paraplegic,  or  monoplegic,  the  paraplegic  being 
most  frequent.  Left-sided  hemiplegia  is  more  common  than  right,  in  the 
proportion  of  about  4  to  i.  Very  frequently  the  local  palsy  is  associated  with 
a  contraction  of  the  opposing  set  of  muscles.  Anesthesia  limited  in  area  to 
the  part  affected  is  to  be  noted,  together  with  a  bluish  discoloration  of  the  skin 
over  the  affected  part.  The  reflexes  may  be  increased,  but  the  electric  reactions 
are  normal  and  atrophy  is  absent.  Hyperesthesia,  aphonia,  and  paralysis 
of  the  bladder  are  usually  associated. 

Spastic  Contractions. — These  may  occur  gradually,  following  paral3'sis, 
but  usually  they  develop  suddenly  and  disappear  rapidly,  at  the  termination 
of  a  variable  period.  Almost  any  group  of  voluntary  muscles  may  be  attacked, 
and  the  distribution  may  be  hemiplegic,  diplegic,  paraplegic,  or  monoplegic. 
The  contracted  part  is  rigid  like  an  iron  bar.  Both  flexors  and  extensors  are 
in  action,  but  the  extensors  usually  predominate. 

In  hemiplegic  cases  there  is  often  associated  complete  analgesia,  deficiency 
of  hearing,  smell,  taste,  and  retraction  of  the  visual  field  on  the  affected  side. 
Next  to  contraction  of  the  arm,  paraplegia  is  most  common.  In  cases  of  long 
standing  a  certain  degree  of  muscular  atrophy  may  be  present,  but  without 
the  reaction  of  degeneration.  True  hysteric  aura,  beginning  in  the  contracted 
part,  terminating  in  globus  hystericus,  and  followed  by  aphonia,  are  sometimes 
observed.     Of  this  nature  also  is  hysteric  club-foot,  described  in  another  section. 

Joint  Disease. — Disease  of  any  articulation  may  be  mimicked,  but  it 
usually  affects  the  knee  or  hip,  spine,  or  lower  jaw.  The  joint  is  usually  hyper- 
sensitive, rigidly  fixed  or  preternaturally  mobile,  and  swollen.  Atrophy  occurs 
from  disease  only,  but  the  electric  reactions  are  unchanged.  Motion  is  painful, 
and  the  patient  walks  with  a  limp.  The  sleep  is  unaffected  and  "night  pains" 
are  absent.  Superficial  hyperemia  may  increase  the  surface  temperature. 
An  occasional  very  high  temperature  of  108°  or  110°  should  excite  suspicion. 

Organic  disease  may  succeed  the  neuromimetic  disturbance,  as  in  the  ankle- 


NEUROMIMESIS.  701 

joint  case  of  Esmarch,  about  which  for  many  weeks  he  was  undecided,  which 
ultimately  proved  to  be  caries  sicca,  requiring  amputation,  and  in  the  remarkable 
knee-joint  case  recorded  in  Weir  Mitchell's  lectures.  In  the  latter  the  hysteric 
element  was  pronounced,  but  on  account  of  its  chronicity  so  eminent  an  authority 
as  Billroth  pronounced  it  organic,  and  Sands,  upon  operating,  found  the  joint 
surfaces  normal  and  non-tuberculous  inflammatory  thickening  outside  the  joint. 
True  permanent  contractures  from  sclerosis  may  follow  the  hysteric  condi- 
tion in  rare  instances,  as  in  a  recent  case  of  a  boy  of  six  years  under  the  care 
of  the  writer.  At  first  the  subject  of  extreme  general  bizarre  contortion  of  all 
the  flexor  muscles,  it  eventually  affected  all  the  extensors  and  was  permanent 
under  full  anesthesia. 

Diagnosis. 

The  presence  of  hysteria  in  any  of  its  protean  forms  should  put  the 
practitioner  on  his  guard  in  regard  to  the  nature  of  any  motor  or  joint  affection. 

The  neuromimetic  paralyses  may  be  gradual  or  sudden  in  onset,  but  are 
usually  associated  with  anesthesia,  paralysis  of  the  bladder,  aphonia,  or  other 
hysteric  manifestation. 

The  neuromimetic  contractions  are  very  deceptive,  but  they  disappear 
under  full  anesthesia.  The  extension  and  rigidity  of  the  part,  the  occurrence 
of  areas  of  anesthesia,  the  occurrence  of  the  so-called  "blue  edema"  of  the 
French,  deficiency  of  the  special  senses,  particularly  retraction  of  the  visual 
field,  and  the  hysteric  aura,  are  of  diagnostic  value. 

The  neuromimetic  joint  affections  have  symptoms  in  common  with  both 
chronic  synovitis  and  chronic  osteitis  of  the  joints.  The  absence  of  true  reflex 
spasm,  the  normal  electric  reaction  of  the  muscles  to  the  faradic  current,  the 
absence  of  a  rise  of  temperature, — either  local  or  constitutional, — and  the  associa- 
tion of  globus  hystericus,  and  of  emotional  attacks  of  weeping  and  crying,  will 
serve  to  distinguish  the  hysteric  affection  from  the  true  organic  disease.  The 
rigidity,  moreover,  yields  to  mild  force  if  the  attention  is  diverted,  and  wholly 
disappears  under  the  usual  doses  of  chloral  or  opium,  and  complete  anesthesia. 

In  doubtful  cases  A;-ray  photography  will  be  found  of  value  in  deciding 
the  question  of  a  true  pathologic  lesion  of  the  joints. 

Treatment . 

The  successful  treatment  of  these  affections  requires  a  knowledge  of  human 
nature,  and  great  tact,  together  with  consummate  skill.     The  general  condition, 


702  ORTHOPEDIC  SURGERY. 

and  particularly  the  general  morale  of  the  patient,  require  attention.  Tonics, 
nerve  sedatives  (with  positive  interdiction  of  morphin),  electricity,  and  massage 
are  of  great  service.  Preparations  of  valerian,  zinc,  and  iron  are  to  be  recom- 
mended. On  account  of  the  frequent  complication  of  neurasthenia,  the  method 
of  Weir  Mitchell  offers  the  best  advantages  and  is  particularly  applicable  to 
these  cases.  It  consists  of  free  nourishment,  isolation,  rest,  massage,  and 
electricity.  The  assistance  of  an  intelligent  nurse  is  essential.  In  regard  to 
the  local  affection— the  neuromimesis — the  treatment  consists  in  diverting  the 
attention  from  the  affected  part.  In  conducting  this  part  of  the  treatment 
a  positive  diagnosis  is  necessary.  This  being  assured,  the  attention  may 
be  diverted  abruptly  or  gradually.  The  first  plan,  which  is  scarcely  legitimate 
in  regular  medical  practice,  consists  in  suddenly  commanding  the  patient 
to  use  the  affected  part,  after  the  method  of  charlatans  and  faith-healers. 
H3^notism  has  of  late  been  extensively  employed  for  the  same  purpose,  but 
is  useful  only  in  selected  cases,  and  is  not  of  much  value  in  neuromimetic 
affections. 

The  second  and  usual  method  consists  in  the  gradual  diversion  of  the 
mind  from  the  affected  part,  and  the  gradual  use  of  the  part.  The  application 
of  mechanical  force  is  positively  contraindicated  and  the  use  of  apparatus 
is  entirely  secondary.  In  spastic  contractions  and  joint  affections  light  traction 
in  the  line  of  deformity  may  be  applied  for  a  time.  The  use  of  the  limb  is  then 
encouraged,  pain  being  disregarded.  Massage  and  electricity  hasten  the  cure, 
the  massage  being  used  daily  as  a  substitute  for  exercise. 

Operative  treatment  is  usually  contraindicated,  but  if  the  contracture 
persist  for  a  long  period,  despite  thorough  treatment,  tenotomy  may  be  resorted 
to,  sufficient  instances  having  been  recorded  to  establish  this  method  of 
procedure. 


CHAPTER  XXIII. 
NEUROPATHIC  AFFECTIONS  OF  JOINTS. 

Charcot's  Disease. 

Destructive  forms  of  arthritis  occur  chiefly  during  the  course  of  locomotor 
ataxia  and  S3Tingomyelia,  but  are  also  found  associated  with  other  diseases 
of  the  central  nervous  system, — especially  lesions  of  the  anterior  cornu, — 
as  cerebral  hemorrhage,  injuries  to  the  spinal  cord  and  peripheral  nerves,  tumors 
of  the  spinal  cord,  acute  myelitis,  anterior  poliomyelitis,  progressive  muscular 
atrophy.  Pott's  disease,  and  stab  wounds  of  the  spinal  cord. 

Synonyms. — Spinal  Arthropathy;  Arthropathy;  Tabetic  Arthropathy; 
Neural  Arthropathy. 

While  particular  attention  has  been  attracted  to  this  subject  by  the  writings 
of  Charcot,  Allbutt,  Raymond,  Hitzig,  Gull,  and  others,  it  is  interesting  to 
observe  that  to  a  distinguished  American  physician  of  Philadelphia,  Dr.  John 
K.  Mitchell,  belongs  the  long-forgotten  credit  of  the  first  discovery  that  an 
"obvious  spinal  cause  may  produce  a  rheumatism  characterized  by  heat,  pain, 
redness,  and  tumefaction,  and  the  direct  connection  between  Pott's  disease  and 
acute  inflammations  of  the  joints,  and  between  traumatism  and  acute  joint 
diseases." 

Etiology. — The  most  common  spinal  arthropathy  is  that  dependent 
upon  degeneration  of  the  posterior  columns,  or  locomotor  ataxia — the  one 
particularly  referred  to  by  Charcot.  Hemiplegic  arthropathies  have  been 
studied.  Two  varieties  have  been  recognized — an  acute  or  subacute  form  and 
a  chronic  form.  The  disease  is  usually  met  in  adults,  but  cases  are  recorded  as 
early  in  life  as  the  sixth  year.  The  right  and  left  sides  of  the  body  are  affected 
about  equally,  and  all  the  major  joints  are  affected  and  many  of  the  smaller 
ones.  Usually  but  one  joint  is  aft'ected,  but  occasionally  two  or  more  are 
diseased.  Of  all  the  large  joints,  the  knee-joint  is  most  frequently  affected. 
Thus  in  the  169  cases  analyzed  by  Weitzacher,  the  knee  was  affected  in  78,  the 
hip  in  31,  the  shoulder  in  21,  etc.  These  occurred  in  109  individuals,  of  whom 
72  were  men,  and  37  women. 

The  frequency  of  arthropathy  in  tables  is  estimated  to  be  about  5  to  8  per 

703 


704  ORTHOPEDIC  SURGERY. 

cent.     Very  frequently  more  than  one  joint  is  involved.     Flatow  gives  the  dis- 
tribution as  follows: 

Knee, 60;  bilateral  in  13  instances. 

Foot, 30;         "         "    9         " 

Hip, .....38;         "         "9 

Shoulder, 27;         "         "6         ' 

In  a  report  of  217  cases  Chepault  gives  the  distribution  as  follows: 

Knee, 120  cases. 

Hip, 57      " 

Foot, 40      " 

There  have  been  15  cases  of  Charcot's  disease  of  the  vertebral  column 
reported. 

Bradford  and  Lovett,  in  a  report  of  107  cases  of  Charcot's  disease,  give  the 
distribution  as  follows: 

Knee, 78  cases. 

Hip, 13      " 

Shoulder, 21       " 

Tarsus, 13      " 

Elbow,  .■ 10      " 

Ankle, 9       " 

Wrist, 2       " 

Jaw, 2      " 

Spine, , I  case. 

The  exact  mechanism  of  the  production  of  these  arthropathies  has  been 
a  matter  of  much  discussion.  The  discovery  of  arthropathies  caused  by  injury 
of  nerve-trunks  promised  to  simplify  the  research,  but  while  it  has  been  shown 
that  they  are  caused  neither  by  vascular  palsy,  vasal  spasm,  nor  by  inertia, 
as  suggested  by  Mitchell,  the  local  nerve  irritation  probably  influences  the 
center,  and  through  it  and  the  entire  nerve  thread  acts  upon  the  joint  to 
disturb  its  nutrition. 

The  theory  that  these  arthropathies  are  only  the  result  of  constant  trauma- 
tism upon  joints  whose  sensitiveness  was  destroyed,  as  in  conjunctival  troubles 
following  section  of  the  facial  nerve,  is  no  longer  tenable.  Virchow's  assertion 
that  the  distinction  is  due  to  faulty  cellular  or  trophic  change  in  the  joint  explains 
nothing.  In  some  cases  without  peripheral  irritation  the  disturbed  centers 
are  capable  of  producing  joint  lesions.  The  tabetic  arthropathies  occur  indepen- 
dently or  precede  the  active  symptoms  of  spinal  lesion.      In  hemiplegic  cases 


NEUROPATHIC  AFFECTIONS  OF  JOINTS. 


705 


the  arthropathy  occurs  from  fifteen  days  to  three  months  after  the  apoplectic 
attack,  coincidently  with  the  advent  of  "late  rigidity,"  a  symptom  commonly 
ascribed  to  descending  sclerosis.  Occasionally  the  arthropathy  may  be 
observed  as  early  as  the  day  after  an  attack  of  hemiplegia,  or  on  the 
third  day. 

Pathology. — The  pathologic  changes  which  occur  in  Charcot's  joint 
disease,  like  those  of  syringomyelia,  resemble  somewhat  those  seen  in  arthritis 
deformans.  There  is  marked  effusion,  which  is  rarely  clear  but  is  generally 
brownish  from  disintegrated  blood  or  may  be  cloudy  from  flocculi.  Fibrous 
degeneration  of  the  articular  cartilage  takes  place,  and  on  account  of  the  con- 


FiG.  531. — Ataxic  Elbow-joint. 


Fig.  532. — Ataxic  Hip-joint. 


tinual  pressure,  is  gradually  destroyed  along  with  the  underlying  bone,  and  re- 
placed by  fibrous  tissue  infiltrated  with  calcareous  salts.  On  account  of  static 
causes  this  degeneration  and  destruction  of  the  cartUage  and  bone  take  place 
unevenly.  There  are  usually  no  areas  of  denuded  bone,  although  section  of  the 
bone  shows  it  to  be  soft  and  eburnated.  As  the  destructive  process  continues 
there  occur  irregular  formations  of  osteophytes,  especially  around  the  periphery 
of  the  articulating  surfaces,  and  hypertrophy  of  the  epiphysis.  Along  the  edge 
of  the  articular  cartilage  marked  proliferation  of  cartilage  and  bone  takes  place 
which  is  continued  into  the  synovial  membrane.  The  entire  synovial  sac  is 
dilated,  and  the  joint  ligaments  are  relaxed  and  later  may  ulcerate.  Spontaneous 
dislocations  may  occur.     Marked  peri-articular  edema  occurs;  whether  this  is 


706 


ORTHOPEDIC  SURGERY 


due  to  a  tear  in  the  capsule  allowing  the  infiltration  of  fluid  from  within  the 
joint  or  is  due  to  a  vasomotor  disturbance  is  not  determined. 

Roberts  systematically  classifies  the  pathologic  changes  as  follows: 

I.  A  chronic  asthenic  hyperemia  of  the  synovial  membrane — a  hydrarthrosis. 


Fig.  S33. — Ataxic  Knee-joint. 


Fig.  534. — Ataxic  Ankle-joint. 


Fig.  535. — Ataxic  Ankxe-joint. 


2.  An  interstitial  atrophy  of  the  epiphyses. 

3.  A  fungous  or  rarefying  epiphyseal  hypertrophy. 

4.  The  formation  of  osteophytes  and  bony  stalactites. 

Symptoms. — The  onset  of  the  arthritis  may   occur   before    the  ataxia, 
but  oftener  the  symptoms  develop  after  signs  of  the  ataxia  are  present.    The 


NEUROPATHIC  AFFECTIONS  OF  JOINTS.  707 

onset  is  usually  sudden,  without  any  history  of  trauma  to  account  for  the  con- 
dition. Marked  peri-articular  edema  extending  well  above  and  below  the 
affected  joint,  superficial  venous  engorgements,  and  tenseness  of  the  skin  follow 
shortly  after  the  onset.  This  swelling  may  pit  on  pressure  or  may  be  very  firm. 
The  pain  may  be  erratic,  paroxysmal,  or  constant  and  there  may  be  exquisite 
tenderness  to  pressure.  In  spinal  cases,  pain  and  sensitiveness  may  be  present 
over  certain  vertebras,  with  an  aching  distress  over  which  ice  develops  a 
feeling  of  burning. 

The  course  of  the  affection  is  varied  and  essentially  chronic.  With 
occasional  exacerbations  years  may  elapse  before  the  disease  becomes 
matured.  Spontaneous  recovery  may  be  abrupt  and  rapid,  or  atrophy  and 
absorption  of  the  cartUages  with  proliferation  of  osteophytes  may  result  in 
total  destruction  of  the  articulation.  Suppuration  has  been  observed,  but  does 
not  form  an  essential  part  of  the  disease. 

The  muscles  become  rapidly  and  extensively  wasted,  and  respond  only  to 
galvanic  currents  of  high  power  (thirty  cells  or  more). 

Diagnosis. — In  the  earliest  stages,  before  the  appearance  of  the  spinal 
or  cerebral  lesion,  it  is  impossible  for  the  most  acute  clinicians  to  distinguish 
these  affections  from  some  of  the  ordinary  types  of  acute  articular  rheumatism. 
According  to  Charcot  and  others,  they  are  to  be  recognized  by  the  limitation 
of  the  affection  to  the  joints  of  the  palsied  members,  their  relation  in  time  to 
hemiplegia  or  other  nervous  lesion,  and  the  coexistence  of  other  trophic  distur- 
bances, as  dystrophy  of  the  nails,  muscular  atrophy,  etc. 

From  tuberculous  osteitis  of  the  joints  they  may  be  distinguished  by  the 
absence  of  reflex  pain,  muscular  spasm,  and  abscess  formation;  and  from 
malignant  disease  of  the  joints  by  the  anamnesis  and  course  of  the  disease, 
and  by  the  presence  of  central  or  peripheral  disturbance. 

Prognosis.— Without  treatment  the  affection  is  self-limited  after  a  variable 
period,  but  repair  to  the  lesion  is  impossible,  and  apparent  diminution  in  the 
deformity  is  usually  due  to  the  disappearance  of  effusion  in  and  about  the 
articulation.  If  the  nervous  lesion  can  be  controlled  or  cured,  recovery  may 
promptly  follow,  as  in  the  cases  recorded  by  Weir  Mitchell. 

Treatment. — The  treatment  consists  in  limiting  or  overcoming  the  central 
nervous  lesion  by  absolute  rest,  the  use  of  tonics,  iodid  of  potassium  or 
ammonium  in  moderate  doses,  and  full  doses  of  strychnin  by  hypodermatic 
injection.     Locally  the  use  of  ice,    massage,  and   the  application  of  a  vrell- 


708  ORTHOPEDIC  SURGERY. 

applied  roller  bandage  or  pressure  sponges  will  afiford  the  greatest  comfort 
and  relief. 

Powerful  galvanic  currents  through  the  joints  and  reversed  galvanic  currents 
have  been  recommended  by  Weir  Mitchell.  If  the  hydrarthrosis  be  excessive, 
aspiration  or  aseptic  incision  may  be  performed.  In  moderate  cases  supporting 
apparatus  will  improve  the  local  condition.  Good  results  in  three  cases  have 
followed  arthrotomy  and  permanent  irrigation  as  reported  by  Lotheissen.  When 
the  disease  is  far  advanced,  excision  or  amputation  is  indicated  and  is  often 
followed  by  good  results. 

Syringomyelia. 

The  arthropathies  of  syringomyelia  so  often  closely  simulate  those  of 
locomotor  ataxia  that  they  deserve  special  mention.  They  usually  occur  after 
the  thirtieth  year,  and  are  more  frequent  in  males  than  in  females,  since  syringo- 
myelia attacks  two  males  for  one  female.  Thus,  of  the  35  cases  of  joint  affections 
in  syringomyelia  analyzed  by  Graf,  26  were  males.  Arthropathies  occur  in 
not  less  than  10  per  cent,  of  the  cases,  and  whereas  in  tabes  from  75  (Schrotter) 
to  80  (Graf)  per  cent,  of  the  affected  joints  are  those  of  the  lower  limbs,  in 
syringomyelia  the  articulations  of  the  upper  limbs  are  generally  affected.  The 
frequency  of  arthropathy  in  syringomyelia  is  estimated  by  Schlesinger  to  be 
about  20  to  25  per  cent.  His  statistics  showing  the  distribution  of  the  affection 
are  as  follows: 

Shoulder, 29  cases 

Elbow, 24 

Wrist, 18 

Hip, 4 

Knee,  7 

Foot, 7 

Other  joints, 8 

97  cases 

N.  A.  Sokolow  reports  a  case  of  s)Tingomyelia  in  which  the  sterno-clavicular 
joint  was  involved.  Thus,  of  51  joints  affected  in  the  35  collected  cases,  39 
were  in  the  upper  and  12  in  the  lower  limbs,  a  difference  readily  explained 
by  the  fact  that  in  syringomyelia  the  cervical  and  upper  dorsal  portions  of 
the  cord  are  those  chiefly  affected.  The  affection  occurs  most  frequently  in 
persons  who  use  their  arms  to  excess,  as  tailors,  butchers,  etc. 

Pathology. — The  pathologic  changes  which  occur  in  the  arthropathies 


NEUROPATHIC  AFFECTIONS  OF  JOINTS.  709 

of  syringomyelia  resemble  to  some  degree  those  seen  in  arthritis  deformans. 
Two  forms  of  the  disease  may  occur — the  hypertrophic  and  the  atrophic  forms. 
In  the  hypertrophic  type  there  are  marked  proliferation  and  osteophytic  formation 
of  the  head  of  the  bone,  which  extends  to  the  shaft  and  the  adjoining  soft  parts, 
producing  enlargement  of  the  bony  ends  of  the  affected  joint.  This  is  accom- 
panied by  effusion,  and  by  relaxation  of  the  capsule  and  tendons  of  the  joints, 
producing  increased  mobility  and  a  tendency  to  dislocation.  Marked  edema 
of  the  extra-articular  structures  occurs.  When  the  joints  of  the  lower  extremity 
are  affected,  destruction  of  the  cartUages  results  from  pressure.  Sequestrum 
formation  is  occasionally  observed.  The  atrophic  tj^e  is  characterized  by 
rarefaction  of  the  bone  even  to  complete  disappearance  of  the  articular  sur- 
faces, which  in  shoulder-joint  disease  resembles  very  much  the  condition  found 
in  "caries  sicca."  Spontaneous  dislocations  are  very  liable  to  occur  and  may 
be  the  first  symptoms  of  syringomyelia.  Fractures  of  the  bones  near  the 
affected  joint  are  occasionally  observed.  The  disease  may  be  so  extensive, 
especially  in  the  shoulder-joint,  that  the  entire  head  and  upper  part  of  the 
shaft  of  the  humerus  may  entirely  disappear. 

The  central  lesion  of  syringomyelia  is  characterized  essentially  by  the 
formation  of  a  cavity  with  gliomatous  walls  in  the  gray  substance  of  the  spinal 
cord,  or  a  simple  dilatation  of  the  central  canal,  which  is  probably  a  congenital 
condition  and  due  to  defective  closure  of  the  tube.  The  cord  may  present 
throughout  its  whole  length  an  epitome  of  the  gliomatous  process  in  all  its 
various  stages. 

Symptoms. — The  condition  may  develop  suddenly,  and  the  first  symp- 
tom of  the  disease  may  be  a  dislocation,  which  at  first  is  thought  to  be  trau- 
matic, but  on  careful  investigation  it  is  found  that  other  symptoms  of  syringo- 
myelia are  present.  There  may  be  prodromal  signs,  as  marked  localized  and 
referred  pains  about  the  affected  joint.  The  course  of  the  arthropathy  is 
generally  much  slower  than  that  of  Charcot's  disease.  There  is  usually  to 
be  obtained  a  history  of  general  symptoms  of  S3T:ingomyelia  to  which  the  patient 
has  paid  no  especial  attention.  These  may  consist  of  deformities  of  the  fin- 
gers, changes  in  the  nails,  scoliosis,  paresthesia,  partial  or  complete  thermic 
and  pain  anesthesia,  more  often  confined  to  the  upper  extremities.  There 
may  be  a  history  of  continued  headaches  and  some  ocular  symptoms.  The 
patient  may  give  a  history  of  gradually  increasing  weakness,  swelling,  pain, 
increased  mobility,  a  recurrent  displacement  of  the  affected  joint  or  joints  ex- 
tending over  a  period  of  years,  to  which,  however,  he  has  given  little  attention 


710  ORTHOPEDIC  SURGERY. 

until  the  acute  symptoms  and  increased  disability  caused  him  to  seek  treatment. 
There  is  generally  a  history  of  injury  immediately  preceding  the  onset  of  the 
joint  symptoms.  Examination  of  the  affected  joint  shows  marked  enlargement 
of  the  peri-articular  structures,  with  atrophy  of  the  muscles  above  and  below 
the  affected  joint.  There  may  be  evidence  of  extravasation  of  blood  in  the 
tissues  above  the  joint,  dilatation  of  the  superficial  veins,  and  the  overlying 
skin  may  be  smooth,  tense,  and  glazy.  There  is  usually  increased  mobility 
of,  and  marked  effusion  in,  the  joint.  The  ends  of  the  bones  are  usually 
enlarged,  distinctly  palpable,  and  there  may  be  a  dislocation  present,  which, 
however,  does  not  interfere  to  any  marked  degree  with  motion,  does  not  cause 
pain,  and  may  be  reducible  by  the  patient.  Sequestrum  formation  and  fis- 
tulas are  very  frequent  in  cases  of  long  standing. 

One  or  more  joints  may  be  simultaneously  affected.  The  course  of  the 
arthropathy  is  more  chronic  than  it  is  in  locomotor  ataxia,  and  the  initial  dis- 
ease may  last  for  twenty  or  twenty-five  years.  The  coexistence  of  arthropathy 
with  syringomyelia  will  be  accounted  for  by  the  discovery  of  postmortem 
indications  of  neuritis  and  atrophy  of  the  peripheral  nerves. 

Syringomyelia,  says  Bruhl,  has  its  own  proper  symptomatology  from 
which  a  clinical  diagnosis  may  be  made. 

Diagnosis. — The  presence  of  an  arthropathy  of  long  duration,  following 
injury  confined  to  the  upper  extremity,  with  the  general  symptoms  of  syringo- 
myelia should  make  the  diagnosis  evident. 

Prognosis. — The  prognosis  for  the  arthropathy  is  very  unfavorable. 
WhUe  the  course  of  the  disease  may  be  extremely  rapid  in  some  cases,  yet  in 
the  majority  the  pathologic  changes  in  the  joint  may  be  so  slow  that  its  func- 
tion is  not  materially  interfered  with  for  years. 

Treatment. — Operative  interference  has  not,  as  a  rule,  been  followed 
by  very  favorable  results.  Slight  operations,  as  the  removal  of  sequestra  and 
the  cureting  of  fistulas,  may  generally  be  accomplished  without  anesthesia. 
If  the  joint  becomes  infected,  arthrotomy,  thorough  irrigation,  and  drainage 
may  be  tried,  but  in  most  cases  this  will  be  found  to  be  ineffectual,  requiring 
resection  or  amputation.  Operative  measures,  except  when  urgently  demanded, 
should  be  limited  to  the  aspiration  of  effusions  under  tension  and  the  removal 
of  sequestra.  Tight  bandaging  will  prevent  reaccumulation  of  the  effusion, 
and  in  all  cases  the  joints  should  be  protected  by  a  suitable  orthopedic  ap- 
paratus, to  prevent  dislocations  and  to  aid  in  the  functional  use  of  the  joint. 


CHAPTER  XXIV. 
UNILATERAL  DEVELOPMENT. 

The  occurrence  of  atrophy  or  hypertrophy  of  a  portion  or  a  half  of  the 
human  body  is  of  interest  to  the  surgeon  from  a  practical  as  well  as  from  a 
scientific  standpoint. 

From  the  Silpi  Sasiri,  the  earliest  known  Sanscrit  manuscript,  Treatise 
on  the  Fine  Arts,  to  the  most  modern  treatises  upon  anthropometry,  the  asym- 
metry of  the  human  body  has  been  recognized,  and  attempts  have  been 
made  to  deduce  the  exact  proportions  of  the  perfect  human  form.  Everything 
tends  to  establish  the  fact  that  the  human  type  of  to-day  is  identical  with  that 
deduced  from  observation  of  the  most  symmetric  ancient  statues.  Quetelet 
and  others  recognized  the  existence  of  a  central  or  typical  forrri  of  man,  I'homme 
moyen,  as  the  mean  result  of  large  numbers  of  actual  measurements  of  living 
men.  Any  deviation  from  this  may  be  considered  as  asymmetry.  Atrophy 
is  most  common,  although  unilateral  hypertrophy  does  sometimes  occur. 

That  this  tendency  to  asymmetry  is  not  confined  to  man  is  illustrated 
by  the  letter  of  Professor  Joseph  Leidy,  in  which  he  says:  "In  the  course  of 
my  studies  in  zoology  and  comparative  anatomy  I  have  had  occasion,  almost 
incessantly,  to  notice  more  or  less  abnormal  symmetry,  in  contradistinction 
to  that  which  must  be  considered  normal." 

The  medicolegal  importance  of  this  subject  has  of  late  received  much 
attention,  particularly  as  it  concerns  inequality  of  the  lower  extremity.  Meas- 
urements have  been  made  by  Hunt,  Cox,  Wight,  and  Morton.  The  examina- 
tion of  boys  in  institutions  bears  testimony  to  the  same  fact.  Thus,  the  meas- 
urements made  by  Morton  showed  inequality  of  the  limbs  in  272  out  of  513 
boys,  the  difference  ranging  from  one-eighth  of  an  inch  to  one  inch  and  five- 
eighths.  The  remaining  241  showed  no  appreciable  variation  in  length.  It 
was  also  noted  that  in  none  of  the  292  boys  suffering  from  inequality  had  there 
been  any  bone  or  joint  disease  or  fracture. 

More  recent  investigation  shows  even  a  larger  proportion  of  inequality, 
and  in  some  of  the  normal  schools  where  my  personal  attention  has  been  called 

711 


712 


ORTHOPEDIC  SURGERY. 


to  the  subject  I  have  found  that  nearly  70  per  cent,  of  the  boys  had  inequality 
of  the  limbs;  and  of  these  all  but  4  per  cent,  were  short  on  the  left  side. 

Roberts  found  by  a  series  of  measurements  in  skeletons  that  a  difference 
existed  in  the  length  of  corresponding  bones  of  the  two  thighs. 

In  the  report  published  by  Garson  on  the  result  of  the  measurement  of 
seventy  skeletons  of  various  ages,  sexes,  and  races,  it  is  shown  that  in  10  per 
cent,  only  were  the  limbs  of  equal  length. 

In^only  five  out  of  eleven  skeletons  measured  by  Dwight  were  the  femora 
equaHn  length.    Variations  in  the  lengths  of  the  tibiae  were  also  found. 


Fig.  536. — Unilai  tkAL  Dtv  iilopment.   Left  Leg. 


Fig.  537. — Same,  Cokj<ected. 


In  some  instances  there  is  also  an  increase  in  the  volume  of  the  part. 
Asymmetry  of  the  upper  extremities  has  also  been  observed  by  Hartwig  and 
Poncet.  The  inequality  may  be  uniform  throughout,  as  in  a  girl  of  twelve 
measured  by  the  author,  in  whom  there  was  a  difference  of  one-fourth  of  an 
inch  in  every  measurement  upon  one  side  of  the  body. 

Etiology. — Various  causes  have  been  assigned,  among  which  may  be 
mentioned  a  neuropathic  disturbance,  a  former  hemiplegia,  a  premature  synos- 
tosis of  the  epiphyseal  cartilages,  a  pathologic  lengthening  following  trauma- 
tism. One  side,  usually  the  right,  may  be  ab  initio  the  stronger,  or  the 
inequality  may  be  due  to  the  passage  of  a  pure  arterial  current  to  one  side. 


UNILATERAL  DEVELOPMENT. 


713 


For  unilateral  development  of  the  lower  extremities  a  simpler  and  equally 
satisfactory  explanation  may  be  found  in  the  fault  of  standing  upon  one  foot 
in  the  attitude  of  fatigue.  This  leads  to  an  increase  in  the  circumference  and 
length  of  the  advanced  limb,  with  a  condensation  and  shortening  of  the  limb 
which  supports  the  weight  of  the  body.  In  time,  if  continued,  this  leads  to 
a  real  inequality  of  from  one-fourth  to  three-fourths  of  an  inch  in  the  length, 
with  a  corresponding  difference  in  the  cirdumferences.  The  long  limb  would 
be  the  hypertrophied  one,  the  short  one  being  comparatively  normal. 


\      f 

Fig.  S38. — Unilateral  Development  showing 
Exaggeration  of  Deformity,  by  Block  on 
Wrong  Side. 


Fig.  ''539. — Unilateral  Development  showing 
13  Correction  of  Deformity,  by  Block  on 
.    Right  Side. 


Symptoms. — The  inequality  of  the  lower  extremities  produces  pain, 
lateral  curvature,  and  a  limp  which  may  be  confused  with  coxalgia  or  infantile 
paralysis.  The  pains  are  usually  neuralgic  in  character  in  the  lumbar,  in- 
guinal, or  anterior  femoral  regions.  Occasionally  they  follow  the  distribution 
of  the  sciatic  nerve.  As  a  result  of  the  lateral  curvature  in  the  lumbar  region 
there  follow  congestion  of  the  spinal  veins,  occipital  headache,  and  neuras- 
thenia, all  of  which  are  most  marked  in  males.  Upon  inspection  of  the  body 
the  changes  in  the  gluteal  folds  are  apparent,  the  fold  on  the  side  of  the  long 
limb  being  higher.      The  pelvis  may  be  twisted  upon  its  axis  also,  and  Bar- 


714 


ORTHOPEDIC  SURGERY. 


well  has  observed  three  forms  of  pelvic  malposition, — obliquity  of  the  pelvis, 
amesiality,  and  version, — all  of  which  are  productive  of  lateral  curvature. 
Diagnosis. — The  difference  can  usually  be  recognized  upon  inspection, 
but  the  amount  of  inequality  of  the  lower  limbs  can  be  determined  by  blocking 
up  the  short  limb  until  it  is  made  equal  in  length  with  its  fellow.  A  better 
and  more  convenient  way  is  by  means  of  a  special  apparatus  devised  for  the 


540- — Author's  Measuring  Machine  tor 
Inequality  of  Lower  Extremities. 


Fig.  541. — S.iME  WITH  Limbs  Equalized. 


purpose,  the  top  of  which  contains  two  movable  platforms  upon  which  the 
individual  stands.  The  short  leg  is  elevated  until  the  folds  of  the  buttocks 
are  level. 

Treatment. — The  treatment  consists  in  restoring  the  S3mimetry  and 
equilibrium  by  artificial  means.  An  attempt  should  always  be  made  by  special 
exercises  to  develop  specially  the  short  limb. 


CHAPTER  XXV. 
RICKETS;    KNOCK-KNEE;   BOW-LEGS. 

Rickets. 

Rickets  is  a  constitutional  disease  of  infants,  acquired  through  malnu- 
trition, characterized  by  impaired  nutrition  and  alterations  in  the  normal  growth 
of  the  bones,  and  terminating  spontaneously  after  a  longer  or  shorter  period. 

Synonyms, — English,  Rachitis;  Rhachitis;  Morbus  Anglicus;  Morbus 
Puerilis;  Articuli  Duplicati.  French,  Rachitisme;  Novure;  Maladie  Anglaise. 
German,  Englische  Krankheit;  Doppelte  Glieder;  Zweiwuchs.  Italian, 
Rachitide.    Spanish,  Raquitis. 

The  term  rickets  here  used,  the  one  popularly  employed  for  nearly  three 
centuries,  is  derived  from  the  Saxon  "rick,"  meaning  a  hump  or  elevation, 
from  a  Dorsetshire  verb  "rucket,"  to  breathe  laboriously,  as  suggested  by 
Trousseau,  or  from  the  Norman  word  "riquets,"  applied  to  deformed  persons. 
For  scientific  purposes,  the  term  rachitis  or  rhachitis  is  more  correct,  the 
former  spelling  having  the  preference,  the  term  being  derived  from  the  Greek 
word  fi^-'/J'^,  "the  spine,"  and  itis,  "inflammation,"  by  the  celebrated  anatomist 
Glisson. 

Etiology. — The  disease  is  universal,  but  is  most  common  among  the 
poor  in  the  larger  cities.  It  is  much  less  frequent  in  the  large  cities  of  this 
country  than  in  Berlin,  Vienna,  or  London,  where  from  50  to  80  per  cent,  of 
all  children  at  the  clinics  are  more  or  less  affected.  In  this  country  it  is  very 
common  among  the  negroes,  Italians,  and  Portuguese.  It  is  said  to  be  com- 
paratively rare  in  Canada,  Greece,  and  Scandinavia;  and,  according  to  Ash- 
mead,  it  does  not  exist  in  Japan.  It  is  sometimes  observed  in  the  country, 
and  is  not  infrequent  among  the  children  of  the  wealthy,  where  it  often  assumes 
the  form  known  as  acute  rickets,  in  reality  a  manifestation  of  scurvy.  The 
severest  cases  occur  in  winter,  from  hygienic  causes  rather  than  from  seasonal 
variation.  The  disease  affects  male  and  female  children  about  equally.  From 
the  obscurity  of  the  etiology  of  this  affection  several  theories  have  arisen.  For 
a  description  of  these  the  reader  is  referred  to  works  upon  pediatrics. 

Rickets  is  usually  an  acquired  affection  due  to  certain  known  predisposing 


716  ORTHOPEDIC  SURGERY. 

and  exciting  causes,  under  the  influence  of  which  almost  any  child  may  have 
rachitis.  The  exceptional  instances  are  those  in  which  the  tuberculous  or  S3rphil- 
itic  diathesis  is  present  and  antagonistic,  and  these  deserve  special  considera- 
tion. Rickets  and  tuberculosis  are  considered  exclusive,  but  tuberculous  men- 
ingitis is,  in  rare  instances,  associated  with  rickets.  The  identity  of  the 
tuberculous  diathesis  and  rickets  was  supported  by  all  the  older  writers.  There 
is,  however,  no  direct  relationship  between  the  two  affections.  A  phthisical 
parent  may  bear  rickety  children,  or  rickety  children  may  become  tuberculous, 
but  children  with  marked  tuberculous  diathesis  rarely,  if  ever,  become  rickety, 
nor  is  it  common  to  find  rickets  in  a  family  where  the  other  chUdren  are  tuber- 
culous. I  have  observed  exceptional  instances  in  which  children  at  first  rachitic 
later  developed  tuberculous  bone  disease  from  an  inherited  diathesis.  The 
belief  in  the  identity  of  rickets  and  syphilis  is  as  ancient  as  the  history  of  medi- 
cine itself.  Rickets  may  afl'ect  the  offspring  of  syphilitic  persons,  but  severe 
rickets  does  not  occur  in  syphilitic  children.  The  belief  that  rickets  is  only 
a  manifestation  of  congenital  syphilis  is  certainly  incorrect.  Syphilis  may 
act  as  a  predisposing  cause  to  rickets  by  impairing  the  constitution.  The 
anatomic  lesions  in  the  two  conditions  are  quite  distinct.  Syphilitic  bones 
very  rarely,  if  ever,  present  the  spongy  tissue  peculiar  to  rickets,  and  rachitic 
bones  never  exhibit  the  multiple  osteophytes  of  syphilis.  When  syphilis  pre- 
cedes rickets,  it  sometimes  produces  those  osseous  deformities  which  have 
been  designated  syphilitic  pseudo-rachitis.  There  is  no  evidence  that  the 
disease  is  ever  transmitted.  Anything  which  impairs  the  general  health  or 
seriously  interferes  with  the  assimilative  power  may  be  considered  as  a  pre- 
disposing cause  of  rickets,  and  improper  food  is  the  exciting  cause.  Want 
of  sunlight,  impure  air,  and  insufficient  exercise  are  important  factors,  but 
given  a  healthy  mother  with  an  abundance  of  milk,  rickets  may  be  escaped, 
no  matter  what  the  character  of  the  surroundings.  Malnutrition  through  the 
use  of  improper  food  is  the  most  common  exciting  cause.  Whatever  unfits 
the  mother's  milk  for  the  nourishment  of  her  child  requires  consideration. 
Gold  cannot  buy  wisdom,  and  wealth,  through  ignorance  and  indolence,  vies 
with  poverty,  through  need  and  necessity,  in  producing  milk  which  is  poor 
in  quality  and  deficient  in  quantity.  The  use  of  artificial  foods  is  said  to  cause 
rachitis  by  deprivation  of  fats  and  phosphates.  This  may  also  be  true  of  the 
mother's  milk.  In  cases  vidth  digestive  disturbances  children  may  be  deprived 
of  these  elements  through  faulty  assimilation.  Too  early  weaning  is  not  so 
common  a  cause  as  too  late  weaning.     Through  some  false  ideas  of  preventing 


RICKETS;  KNOCK-KNEE ;  BOW-LEGS.  717 

conception,  or  through  absolute  ignorance,  children  nursed  from  eighteen  to 
twenty-eight  months  are  particularly  liable.  The  occurrence  of  pregnancy 
during  lactation,  and  too  frequent  pregnancies,  are  likewise  frequent  causes. 
The  possibility  of  the  occurrence  of  rickets  after  any  acute  disease,  particularly 
malarial  fevers,  should  not  be  overlooked. 

Four  varieties  of  rickets  may  be  distinguished: 

1.  Intrauterine  rickets. 

2.  Infantile  rickets. 

3.  Adolescent  rickets. 

4.  Senile  rickets. 

Intrauterine  Rickets. — Since  Ritter  described  and  figured  the  first 
authentic  specimen  of  congenital  rickets  numerous  observers  have  recorded 
similar  examples. 

Two  varieties  of  intrauterine  rickets  are  recognized— /eto/  rickets  and 
congenital  rickets.  Fetal  rickets  is  synonymous  with  achondroplasia  and 
chondrodystrophia  foetalis.  It  is  a  pathologic  process  of  early  fetal  life,  begin- 
ning from  the  third  to  the  sixth  month  of  intrauterine  life  and  terminating 
before  full  term.  In  some  respects  it  resembles  true  rickets:  the  head  is  large, 
the  ribs  are  beaded,  the  epiphyses  are  enlarged,  and  the  shafts  of  the  long  bones 
are  curved.  It  differs  from  congenital  rickets  in  its  early  onset,  atrophic  changes 
in  the  cartilage  of  the  epiphyses,  with  too  rapid  ossification  and  periosteal 
hypertrophy.  The  body  is  abnormally  long  in  proportion  to  the  limbs,  a  con- 
dition resembling  the  dachshund  among  canines.  Fetal  rickets  is  in  some 
obscure  manner  allied  to  the  condition  known  as  cretinism,  and  the  opinion 
has  been  expressed  that  the  cases  of  rickets  which  have  been  described  are 
more  properly  to  be  regarded  as  examples  of  fetal  cretinism.  There  is,  how- 
ever, no  mental  deficiency  in  fetal  rickets. 

The  treatment  consists  of  the  use  of  general  massage,  manipulations  to 
increase  the  range  of  motion  in  the  joints,  and  the  use  of  braces  for  a  time  to 
limit  any  increase  of  bowing  which  would  result  from  the  disproportionate 
weight  of  the  body  upon  the  diminutive  legs. 

Congenital  rickets  is  far  from  uncommon  in  newborn  infants  whose  parents 
have  been  living  in  bad  hygienic  surroundings  during  pregnancy.  Swartz 
out  of  500  infants  born  at  the  Vienna  Clinic  found  80.6  per  cent,  with  typical 
rachitic  changes.  Doubt  has  been  expressed  as  to  the  identity  of  the  lesions 
found  with  the  post-natal  disease.  Congenital  rickets  appears  in  the  later 
months  of  pregnancy  and  develops  subsequently  to  birth.     That  they  are 


718 


ORTHOPEDIC  SURGERY. 


cases  of  true  rickets  would  seem  to  be  established  by  the  specimen  recorded 
by  Ballantyne,  which  likewise  tends  to  confirm  the  opinion  that  the  histologic 
characters  of  true  intrauterine  or  congenital  variety  and  extrauterine  rickets 
are  identical,  by  exhibiting  in  the  same  fetus  characters  peculiar  to  both  fetal 
and  congenital  rickets. 

Infantile  rickets  seldom  appears  before  the  seventh  or  ninth  month, 
most  frequently  between  the  seventh  and  eighteenth  month, 
and  rarely  after  the  second  year. 

Adolescent  rickets  affects  persons  about  puberty 
and  is  usually  associated  with  albuminuria.  In  the  cases 
reported  by  Glutton  and  Drewett,  the  affection  was  iden- 
tical with  the  infantile  variety.  This  form  of  rickets  is 
fairly  common,  and  the  writer  has  observed  it  commencing 
as  late  as  the  eighteenth  year.  The  cause  in  the  observed 
cases  was  apparently  faulty  nutrition.  In  one  remarkable 
instance  bow-leg  began  in  a  youth  of  eighteen  from  using 
a  liquid  diet  on  account  of  a  supposed  stricture  of  the  eso- 
phagus. 

Senile  rickets,  first  described  by  Reeves,  occurs  dur- 
ing adult  and  advanced  life.  Durham  has  collected  145 
cases,  most  of  which  were  associated  with  chUdbirth.  It 
is  rarely  met  outside  of  the  Rhine  provinces,  and  is  fre- 
quently confounded  with  osteitis  deformans. 

Pathology, — The  most  important  pathologic  lesions 
are  in  the  bones,  and  especially  in  the  epiphyseal  junc- 
tures of  the  long  bones  and  the  ribs.  In  normal  bony 
growth  the  development  depends  upon  three  conditions: 
the  lengthening  from  cells  furnished  by  the  cartilages  be- 
tween the  epiphysis  and  diathesis,  the  thickening  from  cell  proliferation  by  the 
inner  layers  of  the  periosteum,  and  the  according  enlargement  of  the  medullary 
canal  by  the  loss  of  the  inner  bone  layers.  This  growth  in  rachitic  bones  is  ex- 
cessive and  irregular,  while  the  actual  ossification  is  wanting  or  imperfect.  The 
bone-tissue,  owing  to  the  sudden  growth  and  irregular  calcification,  is  irregular 
and  spongy,  and  unfitted  to  bear  the  body-weight.  The  peculiar  enlargement 
of  the  joints  is,  of  course,  owing  to  the  cartilaguious  over-production  and  the 
flattening  of  the  soft  bone  by  the  body-weight.  The  medullary  canal  is  larger 
and  the  inner  bone  layers  are  spongy.     The  medulla  is  congested,  and  if  fat  is 


Fig.  542. — Infantile 
Rickets,  showing 
Bossy  Feontals, 
Lateral  Thor- 
acic Grooves  and 
"Rachitic  Ros- 
ary," Large  Ab- 
domen, and  De- 
formities OF  Ex- 
tremities. 


RICKETS;  KNOCK-KNEE;   BOW -LEGS. 


719 


present  it  may  be  absorbed  and  a  species  of 
osteitis  be  present.  The  cartilage  at  these  locah'- 
ties  between  the  shaft  and  epiphysis,  normally 
represented  by  two  narrow  bands  one  or  two 
millimeters  in  thickness,  is  greatly  thickened, 
from  five  to  fifteen  millimeters  in  width,  reddish- 


1 

1 

B 

^  ^^^^^H 

1 

1 

N 

}m 

^H 

lU 

1 

1 

1 

m 

1 

^^  ''')! 

M 

Fig.  543. — Specimen  Bow-legs. 


Fig.  544. — Bow-legs,  showing  Structure. 

gray,  translucent,  irregular  in  outline  and  softer, 
and  the  entire  epiphysis  is  enlarged  and  softened. 
The  microscopic  appearance  shows  changes  at 
the  area  of  normal  ossification.  The  columns  of 
cartilage  cells  are  irregular  in  shape  and  size,  and 
many  cells  show  absence  of  true  ossification,  while 
the  medullary  spaces,  enlarged  in  size  and  irreg- 


720  ORTHOPEDIC  SURGERY. 

ular  in  shape,  encroach  upon  the  area  of  calcification  and  are  filled  with 
"osteoid  tissue."  The  periosteum  is  thickened  and  infiltrated,  as  is  also 
the  underlying  bone  structure,  with  spongoid,  jelly-like  fluid.  The  result 
of  these  changes  is  imperfect  or  delayed  ossification,  and  the  deposit  of 
lime  salts  is  arrested.  The  relation  of  organic  to  inorganic  matter  in  the 
bones  is  very  much  increased,  the  diminution  of  calcareous  salts  being  as  low 
as  25  to  35  per  cent.  In  the  cranial  bones  large  areas  of  imperfect  ossification 
are  met,  giving  rise  later  to  areas  of  atrophy  and  premature  hyperostosis.  Later, 
the  deposit  of  lime  recommences  and  advances  with  undue  rapidity,  producing 
a  condition  of  eburnation  or  petrifaction  in  the  bones.  The  pathologic  anatomy 
of  rickets  may  therefore  be  regarded  as  a  hyperemia  of  all  the  bone-forming 
structures  as  the  primary  lesion.  The  spleen,  liver,  and  sometimes  the  mes- 
enteric glands,  are  enlarged.  Catarrh  of  the  alimentary  and  respiratory 
passages  is  usually  present.  The  brain  is  usually  hypertrophied,  and,  with 
the  membranes,  is  unusually  vascular.  The  voluntary  muscles  are  pale, 
soft,  and  flabby,  and  the  ligaments  are  soft  and  relaxed.  The  blood-changes 
are  usually  those  of  anemia.  There  is  leukocytosis  and  decrease  in  the 
number  of  red  corpuscles,  some  of  which  are  nucleated.  The  leukocytosis 
consists  of  a  special  increase  of  mononuclear  elements  and  there  may  be  myelo- 
cytes. 

Symptoms. — The  symptoms  of  rickets  are  well  marked  and  character- 
istic, and  may  for  convenience  be  included  under  three  divisions:  (i)  Incuba- 
tion; (2)  deformation;  and  (3)  recovery. 

Incubation. — Preceding  the  period  of  bone  change,  there  are  certain 
characteristic  symptoms  which  are  liable  to  be  overlooked.  Loss  of  appetite, 
occasional  vomiting,  impaired  digestion,  flatulence,  constipation  alternating 
with  diarrhea,  the  stools  being  mucous,  green,  often  frothy  and  extremely 
offensive,  indicate  disturbances  of  digestion  which  frequently  precede  but  are 
not  invariable  precursors  of  this  afi'ection.  The  skin  is  pale  and  at  first  gener- 
ally moist,  afterward  hot  and  dry;  the  flesh  is  plump,  though  flabby,  the  ab- 
domen distended,  and  the  anterior  fontanel  depressed.  Associated  with  these 
digestive  disorders  are  two  symptoms  which  are  characteristic  of  the  first  stage 
— local  sweatings  and  nocturnal  fever,  the  early  recognition  of  which  wUl  be 
of  the  greatest  importance.  The  local  sweatings  are  chiefly  confined  to  the 
head,  neck,  and  upper  part  of  the  chest  and  back.  These  portions  are  cold 
and  damp,  in  marked  contrast  to  the  rest  of  the  skin,  which  is  hot  and  dry. 
They  occur  usually  during  sleep,  but  may  be  induced  by  motion  or  exercise. 


RICKETS;  KNOCK-KNEE;   BOW -LEGS.  721 

Upon  the  forehead,  face,  and  neck  the  perspiration  appears  in  large,  clear 
drops,  and  is  often  associated  with  a  copious  eruption  of  miliary  vesicles.  As- 
sociated with  this  local  sweating  the  skin  is  hot,  dry,  and  uncomfortable,  lead- 
ing to  great  restlessness  and  a  disposition  to  kick  the  clothes  off  at  night,  even 
in  the  coldest  weather.  The  pillow  is  thus  often  wet  with  perspiration,  whUe 
the  limbs  are  hot,  dry,  and  uncovered. 

Deformation. — The  commencement  of  morbid  changes  in  the  bones 
is  marked  by  general  hyperesthesia  or  tenderness,  first  exhibited  by  signs  of 
uneasiness  upon  motion;  the  tenderness  increases  untU  the  slightest  involun- 
tary movement  causes  pain,  even  the  approach  of  persons  produces  fear  and 
aversion,  and  the  child  prefers  to  remain  quiet,  motionless,  and  alone.  The 
veins  upon  the  head  and  scalp  are  enlarged  and  prominent,  general  hyperemia 
of  the  cranium  and  scalp  exists,  and  the  carotid  arteries  and  jugular  veins 
are  disproportionately  large.  The  digestive  derangement  continues;  consti- 
pation is  not  uncommon,  and  diarrhea  and  constipation  frequently  alternate; 
the  urine  is  abundant  and  loaded  with  phosphates,  the  appetite  is  voracious, 
the  abdomen  is  distended,  the  flesh  is  soft,  flabby,  and  in  some  instances  ema- 
ciated, and  the  skin  pale. 

These  prodromal  symptoms  are  prolonged  into,  and  may  even  increase 
in  severity  during  the  stage  of  bone  lesion.  The  changes  in  the  bones  which 
lead  to  deformity  may  be  divided  into  three  stages: 

1.  The  stage  of  congestion  or  invasion. 

2.  The  stage  of  softening  or  deformity. 

3.  The  stage  of  hardening  or  sclerosis. 

In  children  in  whom  the  disease  has  commenced  at  the  beginning  of  teeth- 
ing, about  the  sixth  or  eighth  month,  the  final  stage  is  usually  reached  about 
the  third  year. 

All  the  bones  are  simultaneously  affected,  but  the  order  in  which  de- 
formity usually  appears  is,  first,  the  trunk;  second,  the  head;  third,  the 
extremities. 

Trunk.  Among  the  first  bony  lesions  are  the  changes  in  the  epiphyseal 
junction  of  the  ribs,  forming  the  so-called  rickety  rosary,  a  series  of  bead-like 
enlargements  easily  felt  beneath  the  skin.  Important  changes  occur  in  the 
thorax.  The  transverse  diameter  being  sometimes  less  than  the  antero-pos- 
terior,  the  bodies  of  the  ribs  are  bent,  forming  a  groove  just  outside  the  junction 
of  the  cartilages;  the  lower  border  of  the  thorax  is  pushed  out  by  the  enlarged 
liver  and  spleen,  forming  a  transverse  groove,  the  so-called  Harrison's  groove, 

47 


722 


ORTHOPEDIC  SURGERY. 


passing  outward  just  below  the  fold  of  the  pectoral  muscle.  The  sternum 
projects  forward  like  the  prow  of  a  ship,  forming  the  so-called  pigeon-breast 
or  chicken-breast.  Attention  has  been  particularly  directed  to  diastasis  of  the 
abdominal  recti  muscles  by  Francine.  Changes  also  occur  in  the  spinal  column ; 
an  antero-posterior  curve,  a  simple  exaggeration  of  the  normal  curves  through 
weakness  and  long-continued  sedentary  position,  being  most  common.  Lateral 
curvature  is  also  a  common  deformity,  and  lordosis,  as  a  compensatory  affec- 
tion, sometimes  occurs  and  may  persist.  The  lordotic  appearance  is  in- 
creased by  the  large  size  of  the  abdomen.  Changes  in  the  pelvis  occur  from 
the  sedentary  position  and  from  the  pressure  of  the  heads  of  the  thigh  bones. 
Illustrations  of  this  are  common  in  all  obstetric  treatises.     The  abdomen  is 

greatly  enlarged  from  several  causes — contrac- 
tion and  depression  of  the  diaphragm,  from 
the  diminished  capacity  of  the  thorax,  in- 
creased shallowness  of  the  pelvis,  tympany, 
and  enlargement  of  the  liver  and  spleen. 

Head.  The  head  of  a  rickety  chUd  is 
large  and  misshapen,  and  the  fontanels,  par- 
ticularly the  anterior,  which  normally  should 
close  about  the  eighteenth  month,  remain  open 
until  the  end  of  the  third  or  fourth  year  and 
ossification  may  not  be  complete  untU  the  ter- 
mination of  the  sixth  or  even  the  ninth  year. 
There  are  two  varieties  of  skull  typical  of 
rickets — the  oblong  head,  such  as  is  met  in 
negro  children,  and  the  square  head,  the  more 
common  variety,  which  seen  from  above  is  rectangular,  the  capiit  quadrahim. 
The  forehead  is  high,  the  frontal  and  parietal  protuberances  prominent,  and 
the  comparative  smallness  of  the  face  is  characteristic.  Another  peculiarity  is 
imperfect  ossification,  particularly  in  the  parieto-occipital  regions,  the  so-called 
soft  occiput,  or  cranio  tabes.  This  deficiency  of  ossification  is  preceded  by 
thickening  and  softening  of  the  bone.  These  softenings  are  round  or  oval  spots, 
from  one  to  twenty-five  in  number,  situated  just  within  the  sutural  margins, 
and  give  the  sensation  of  an  orifice  closed  by  cartridge  paper.  The  normal 
process  of  dentition  is  ordinarily  retarded,  and  the  eruption  is  irregular  in 
time  of  appearance  and  position,  and  attended  with  great  pain.  Teeth  which 
have  appeared  decay  early,  and  at  eighteen  months  or  two  years  very  few  teeth 


Fig.  545. — Photograph  of   Case  of 
Rachitic  Spine. 


RICKETS;  KNOCK-KNEE ;   BOW-LEGS. 


723 


may    remain.     Cerebral    development    in    rickets    is    usually    retarded;    the 
intellect  is  dull. 

Extremities.     The  alterations  in  the  long  bones  occur  early,  commencing 


Fig.  546. — Rachitic  Kyphosis.     Lateral  View. 


first  and  affecting  most  seriously  those  parts  which  have  a  thin  covering  of 
soft  parts,  such  as  the  wrist,  elbow,  knee,  and  ankle.  The  increase  in  size 
of  the  epiphyses  is  real  and  gives  an  appearance  of  an  additional  joint,  the 


724 


ORTHOPEDIC  SURGERY. 


victims  of  this  affection  sometimes  being  spoken  of  as  double-jointed.  The  length 
and  circumference  of  the  shaft  are  also  less  than  normal.  From  softening  and 
imperfect  ossification  of  the  bones,  any  or  all  of  the  long  bones  may  be  bent  or 
twisted.  These  deformities  have  been  ascribed  to  muscular  action,  gravity,  the 
w^eight  of  the  body,  and  atmospheric  resistance.  Most  of  these  deformities  may 
be  accounted  for  by  the  weight  of  the  body,  gravity,  and  the  peculiar  position  occu- 
pied by  the  chUd.     The  weight  of  the  body  upon  the  softened  neck  of  the  femur 


Fig.  547. — Rickets,  showing  Deformity  of  Chest. 


Fig.  548. — Knock-knee  and  Bow-legs. 


often  produces  coxa  vara,  a  condition  fully  described  elsewhere.  Subluxation  of 
the  inner  end  of  the  clavicle  has  been  observed.  Flat-foot  is  present  in  almost 
all  cases  of  rickets.  It  occurs  usually  before  the  seventh  year,  either  alone 
or  associated  with  knock-knee.  Associated  in  certain  cases  with  the  deformity 
is  a  pseudo-paraplegia,  known  as  Parrot's  disease,  from  excessive  tenderness 
of  the  periosteum,  which  prevents  the  chUd  from  walking,  and  sometimes  from 
standing.  The  muscles  are  atrophied  and  weak,  but  there  is  no  permanent 
nervous  lesion.     The  electric  reactions  are  normal,  the  reflexes  are  not  exag- 


RICKETS;   KNOCK-KNEE ;  BOW -LEGS.  725 

gerated,  and  the  pseudo-paralysis  is  due  to  a  periosteal  tenderness  of  the  mus- 
cular insertions  and  muscular  weakness. 

Complications. — Children  affected  with  marked  rickets  are  especially 
predisposed  to  certain  diseases,  to  one  of  which  death  is  usually  directly 
attributed.  These  include  laryngismus  stridulus,  convulsions,  chronic  hydro- 
cephalus, bronchitis,  and  diarrhea.  These  belong  more  particularly  to  pedia- 
trics and  may  be  omitted  here. 

Recovery. — Though  death  often  occurs  from  some  intercurrent  affection, 
the  disease  frequently  terminates  favorably,  the  recovery  being  perfect.  All 
the  symptoms  subside  and  gradually  disappear,  the  bones  become  exceed- 
ingly thick  and  very  hard,  the  muscles  short,  thick,  and  very  firm;  the  epiphy- 
seal enlargements  diminish,  and  serious  deformities  of  the  long  bones  and 
throat  diminish  remarkably,  and  may  entirely  disappear  within  a  few  months. 

Prognosis. — The  tendency  of  uncomplicated  rickets  is  to  spontaneous 
recovery  after  a  variable  period.  The  danger  lies  in  the  complications — 
degeneration  of  the  viscera,  catarrhal  affections  of  the  respiratory  passages,  diar- 
rhea, hydrocephalus,  and,  in  very  rare  cases,  laryngismus  stridulus.  Under 
efficient  treatment  the  disease  is  very  tractable,  and  the  prognosis  as  to  life 
is  good,  unless  some  complications  arise.  If  the  disease  be  early  arrested, 
the  bony  deformities  and  the  kyphosis  and  lordosis  aU  tend  to  diminish,  but 
the  full  stature  is  seldom  attained  by  adults  who  have  been  affected  in  early 
life.  Such  patients  may  subsequently  become  marvels  of  endurance  and 
strength   and  live   to  a  great  age. 

Treatment. — The  treatment  of  rickets  should  be  hygienic,  dietetic,  and 
medicinal. 

The  hygienic  treatment  should  include  the  selection  of  a  proper  diet  and 
the  improvement  of  the  entire  surroundings  of  the  child.  A  daily  bath  in  tepid 
salt-water,  with  vigorous  rubbing,  should  be  given,  and  the  child,  warmly 
clad  in  warm  woolen  clothing  and  carefully  wrapped,  should  spend  the  greater 
part  of  the  day  in  the  fresh  air  and  sunshine  on  all  except  windy  days.  A  flan- 
nel bandage  about  the  abdomen  should  always  be  worn,  summer  and  winter. 

Frequent  pregnancies  and  nursing  a  child  during  pregnancy  are  important 
etiologic  factors  to  be  overcome.  If  a  nursing  woman  become  pregnant,  or 
the  mother  is  unhealthy,  or  cannot,  from  other  cause,  nurse  the  child,  the  child 
should  be  artificially  fed.  If  the  child  be  bottle-fed,  the  most  rigid  system 
of  cleanliness  must  be  enforced  to  maintain  sterilization  of  the  food.  If  the  patient 
reside  in  a  cold,  damp  locality,  a  change  to  the  dry,  bracing  air  of  mountain, 
country,  and  especially  seashore,  is  often  of  great  benefit.     Seashore  hospi- 


726  ORTHOPEDIC  SURGERY. 

tals,  established  both  in  this  country  and  abroad,  are  excellent  resorts  for  rach- 
itic children,  and  the  "day  nurseries"  in  our  large  cities  accomplish  much 
good  by  the  proper  feeding  and  care  of  the  children.  The  bowels  should  be 
regulated  by  castor  oil,  olive  oil,  "rhubarb  and  soda  mixture,"  or  compound 
licorice  powder.  The  diet  of  a  rachitic  child  is  most  important.  If  there  is 
any  tendency  to  scurvy,  orange  juice,  raw  scraped  apples,  fresh  grape  juice, 
or  grapes  without  skins  or  seeds  will  be  found  of  value.  For  full  details  of 
proper  diet,  the  reader  should  consult  works  upon  diseases  of  children. 

Fish  should  be  largely  used  by  nursing  mothers.  Indeed,  Ashmead 
ascribes  the  absence  of  rickets  in  Japan,  among  other  reasons,  to  the  large 
use  of  fish,  crustaceal  and  iodized  seaweed,  oOs  of  fish,  blubber  of  whale,  and 
especially  loach,  by  nursing  women,  the  children  being  all  breast-fed  and 
suckled  for  a  very  long  period,  the  Japanese  women  having  also  an  enor- 
mously large  supply  of  milk. 

Medicinal  treatment  is  secondary  in  importance  to  the  foregoing.  The 
general  condition  should  be  improved  by  cod-liver  oil,  which  is  considered  by 
many  a  specific,  and  which  has.  long  been  a  common  remedy  on  the  shores 
of  the  Baltic.  It  may  be  given  pure,  in  teaspoonful  doses,  or,  what  the  writer 
prefers,  in  an  emulsion  with  the  lacto-phosphate  of  lime.   The  latter  formula  is : 

R.     01.  morrhua?, gvj. 

Syr.  calcis  lacto-phosphatis, 

Aq.  calcis, aa  giij. 

Sig. — o]  or  3ij  three  times  a  day. 

Another  excellent  combination  is  with  maltine,  or  maltine  and  syr.  calcis 
lacto-phosphatis.  It  may  also  be  rubbed  into  the  legs,  arms,  and  abdomen 
at  bedtime.  Syrup  of  hypophosphites  is  another  excellent  remedy,  and  may 
be  used  in  summer  to  alternate  with  the  oU.  Iron  is  highly  recommended 
by  all  authorities,  and  may  be  given  in  the  form  of  h3qDophosphite,  the  wine 
of  iron,  the  citrate  of  iron  and  quinin,  or,  preferably,  the  syrup  of  the  iodid 
of  iron.  Phosphorus  has  been  recommended,  and  reports  are  favorable  in 
this,  as  in  all  wasting  diseases  of  the  bone.  It  is  usually  given  to  children  in 
TTTj^-grain  doses,  dissolved  in  oil,  three  times  a  day.  A  more  palatable  form 
is  Thompson's  solution,  the  formula  for  which  is  as  follows: 

R .     Phosphori, gr.  j. 

Alcohol,  absolut., nLcccl. 

Spt.  menth.  pip Tt^_x. 

Glycerina?, f^ij. 

Sig. — For  a  child  two  to  four  years,  6  minims,  t.  i.  d.,  increased  to  lo  minims. 
Strength  gr.  ^V  to  3j. 


RICKETS;  KNOCK-KNEE;  BOW-LEGS.  727 

The  results  of  phosphorus  treatment  are  contradictory,  and  the  writer 
has  more  confidence  in  the  other  drugs  mentioned. 

The  surgical  treatment  includes  the  correction  of  knock-knee,  bow-legs, 
and  anterior  bow-legs.  For  dislocation  of  the  clavicle,  Gibney  advises  the 
subcutaneous  injection  of  alcohol  around  the  articulation  and  binding  the 
parts  with  a  roller  bandage. 


Knock-knee. 

Ejiock-knee,  or  genu  valgum,  is  that  deformity  in  which  the  knee  is 
thrown  inside  a  perpendicular  line  drawn  from  the  head  of  the  femur  to  a  point 
midway  between  the  malleoli;  in  other  words,  where  the  bones  of  the  leg  form 
an  abnormal  angle  opening  outward  with  the  bones  of  the  thigh — an  abduc- 
tion contracture. 

Synonyms. — English,  In-knee.  French,  Genou  en  dans;  Genou  Cag- 
neux.  German,  X-Bein;  Knickbein;  Ziegenbein;  Backerbein;  Knieng; 
Kniebohrer;  Schemmelbein.  Italian,  Ginocchio  Torto  all'  Indentro.  Latin, 
Genu  Introrsum.     Greek,  Entogonyancon.     Spanish,  Rodella  al  interno. 

Occurrence. — The  deformity  is  frequently  met  in  surgical  practice,  but 
is  not  so  common  as  bow-legs.  Thus,  of  6400  cases  of  general  surgical  disease 
in  children  treated  at  the  New  York  Orthopedic  Hospital  and  Dispensary, 
there  were  270  cases  of  knock-knee  and  400  cases  of  bow-legs.  In  5860  cases 
of  general  orthopedic  affections  treated  at  the  Orthopedic  Dispensary  of  the 
Hospital  of  the  University  of  Pennsylvania,  77  were  cases  of  knock-knee,  and 
169  were  cases  of  bow-legs.  Boys  appear  to  be  more  frequently  affected  than 
girls. 

Congenital  cases,  though  rare,  do  occur,  and  both  knock-knee  and  bow- 
legs have  been  observed  in  the  newborn.  The  extremely  rare  variety  of  genu 
valgum  which  follows  congenital  luxation  of  the  patella  belongs  under  this 
head. 

The  deformity  usually  appears  when  the  child  begins  to  walk,  between 
the  ages  of  two  and  four^ — genu  valgum  rhachiticum  infantum;  or  about  ado- 
lescence, between  the  ages  of  twelve  and  eighteen — genu  valgum  adolesceniium. 

The  congenital  form  is  usually  the  expression  of  general  rickets. 

The  acquired  forms  present  several  varieties,  which  may  be  grouped  into: 
(i)    Rachitic;    (2)  Atonic;    (3)  Paralytic;    (4)  Arthritic;   and  (5)  Traumatic. 

I.  The  rachitic  variety  includes  almost  all  the  cases  occurring  during  the 


728  ORTHOPEDIC  SURGERY. 

first  period,  and  many  authorities  would  include  some  of  those  also  which  occur 
at  puberty,  and  consider  the  process  a  local  rachitic  one — a  form  of  "latent 
rickets." 

Rickets  softens  the  bones,  weakens  the  muscles,  and  relaxes  the  ligaments, 
and  the  superincumbent  weight  of  the  body  accomplishes  the  rest.  Genu 
valgum  in  these  cases  is  simply  the  local  manifestation  of  a  constitutional 
diathesis. 

2.  The  atonic  or  statical  variety  affects  individuals  of  feeble  physique 
about  the  time  of  puberty — genu  valgum  staticum  sive  adolescentium — whose 
occupations  compel  them  to  stand  most  of  the  time.  Carpenters,  waiters, 
cooks,  young  bricklayers,  and  especially  bakers,  who  work  in  a  warm,  moist 
atmosphere,  and  carry  heavy  loads  of  bread,  are  most  liable  to  be  affected. 
They  exhibit  no  evidence  of  rickets,  but  suffer  from  relaxation  of  the  ligaments 
and  muscles. 

I  The  production  of  this  form  of  genu  valgum  is  usually  the  result  of  faulty 
positions  assumed  from  weakness  or  fatigue. 

The  normal  human  individual  stands  erect  with  a  certain  amount  of  knock- 
knee,  the  femurs  form  an  angle  with  each  other  of  15  degrees  or  more,  and 
an  imaginary  line  drawn  from  the  head  of  the  femur  falls  outside  the  center 
of  the  knee-joint.  To  compensate  for  this  the  normal  internal  condyle  of  the 
femur  is  from  one-quarter  to  one-half  inch  longer  than  the  external. 

Children  and  adults  of  feeble  physique  instinctively  assume  a  valgoid 
position  with  the  knees  extended  and  the  feet  everted  and  separated,  the  so- 
called  "attitude  of  rest,"  a  position  in  which  ligamentous  is  substituted  for 
muscular  support,  and  the  limbs  placed  in  a  position  most  favorable  for  the 
production  of  this  deformity.  Unilateral  knock-knee  sometimes  results  from 
the  pressure  of  the  mother's  arm  upon  the  softened  bones  when  the  child  is 
carried  constantly  upon  one  side.  Flat-foot  is  often  associated  in  this  form 
as  well  as  in  the  rachitic,  sometimes  as  causative,  as  a  secondary  condition, 
or  both  may  result  from  the  same  faulty  attitude. 

It  has  been  suggested  that  asymmetry  may  be  an  important  factor  in  the 
genesis  of  this  form  of  knock-knee. 

3.  The  paralytic  varieties  are  met  with  in  connection  with  infantile  spinal 
paralysis  and  in  spastic  paraplegia. 

Trophic  disturbances  affect  the  nutrition  of  the  bones,  ligaments,  and 
muscles.  The  bones  are  more  curved,  thinner,  and  softer  than  normal;  the 
ligaments  are  relaxed,  and  the  muscles  have  their  equilibrium  destroyed,  not 


RICKETS  ;  KNOCK-KNEE  ;  BOW -LEGS.  729 

from  loss  of  muscular  antagonism,  but  from  growth  while  the  part  remains 
in  an  abnormal  position. 

4.  The  arthritic  variety  includes  the  few  cases  which  result  from  destruc- 
tive disease  of  the  joint,  the  so-called  genu  valgum  inflammatorium,  from 
tuberculous  osteitis,  rheumatoid  arthritis,  osteomalacia,  osteomyelitis,  osteo- 
arthritis, etc. 

5.  The  traumatic  form  occurs  from  fractures  of  condyles  of  the  femur 
or  of  the  articular  facets  of  the  tibia,  and  in  rare  cases  from  over-correction 
after  osteotomy  for  genu  varum. 

The  chief  theories  which  have  been  advocated  to  explain  this  deformity 
may  be  included  under  three  heads:  (i)  The  ligamentous  theory.  (2)  The 
muscular  theory.     (3)  The  osseous  theory. 

The  ligamentous  theory  considered  either  that  the  internal  lateral  ligament 
was  primarily  relaxed,  permitting  lateral  and  downward  hjq^ertrophy  of  the 
internal  condyle  of  the  femur;  or  that  the  external  lateral  ligament  was  pri- 
marily shortened,  producing  pressure  atrophy  or  deficiency  of  growth  of  the 
outer  condyle.  According  to  some  observers,  the  internal  ligaments  of  the 
joint,  principally  the  crucial,  are  largely  concerned  as  causative  agents. 

The  muscular  theory  assumes  either  a  primary  shortening  of  the  biceps 
popliteus,  and  tensor  vaginae  femoris  muscles,  or  a  primary  relaxation  of  these 
same  structures. 

The  osseous  theory  assumes  a  primary  rachitic,  inflammatory,  or  other 
osseous  changes  in  the  epiphysis  or  lower  portion  of  the  femur  or  the  upper 
part  of  the  tibia,  producing  hypertrophy  of  the  inner  portion  of  the  joint,  with 
or  without  atrophy  of  the  outer  portion. 

The  defective  growth  of  the  external  condyle  has  been  ascribed  to  pre- 
mature inflammatory  synostosis  of  the  outer  part  of  the  epiphyseal  cartilage 
from  excess  of  pressure.  Malnutrition  of  the  epiphyses,  the  result  of  central 
changes  having  their  expression  in  the  epiphyseal  cartilages  of  the  knee-joint, 
has  been  suggested  as  a  cause. 

These  theories  have  been  formulated  to  explain  the  pathologic  findings 
m.  genu  valgum,  but  in  the  majority  of  instances  no  one  theory  will  account 
for  the  production  of  this  affection.  In  many  cases  rachitis  is  the  sole  cause; 
in  a  large  number  the  statical  conditions,  with  or  without  rickets,  are  causative ; 
in  others  paralysis,  local  disease,  or  traumatism,  are  etiologic  factors.  In  all 
cases,  after  the  condition  is  once  established,  the  superincumbent  weight  of 
the  body  is  an  important  factor  in  increasing  the  deformity. 


730  ORTHOPEDIC  SURGERY. 

Pathology. — The  morbid  anatomy  will  depend  upon  the  stage  of  the 
affection  and  the  degree  of  deformity. 

In  the  rachitic  form  the  most  important  changes  are  in  the  bones  forming 
the  knee-joint. 

The  elongation  of  the  internal  condyle  is  both  apparent  and  real;  the 
external  condyle  is  atrophied  and  sclerosed,  and  the  entire  lower  epiphysis 
of  the  femur  is  broadened,  shortened,  and  obliquely  placed  upon  the  shaft, 
from  the  lengthening  of  the  inner  side  of  the  lower  part  of  the  diaphysis. 

In  some  cases  the  lower  epiphysis  of  the  femur  is  tndsted  or  rotated  out, 
while  in  others  the  upper  epiphysis  of  the  tibia  is  oblique  and  rotated  generally 
outward,  in  rare  cases  inward,  and  the  femur  is  apparently  normal.  The 
shafts  of  the  femur  and  tibia  are  bent  above  and  below  the  joint,  and  in  some 
cases  at  the  upper  part  of  the  shaft  of  the  femur  and  the  lower  part  of  the  shaft 
of  the  tibia. 

The  density  of  the  osseous  structure  depends  upon  the  stage  of  the  morbid 
process,  being  a  little  softer  than  normal  bones  during  the  stage  of  vascularity, 
as  soft  as  cheese  during  the  stage  of  softening,  and  as  hard  as  ivory  in  the  stage 
of  consolidation. 

The  articular  cartilages  are  hypertrophied  on  the  outer  side  and  atrophied 
upon  the  inner  side. 

The  internal  lateral  ligament  is  elongated  and  relaxed  and  h}^ertrophied. 
The  external  lateral  ligament  is  contracted,  and  in  some  cases  the  crucial 
ligaments  are  atrophied  or  entirely  absent. 

The  muscles  upon  the  outer  side  are  shortened,  and  those  upon  the  inner 
side  are  relaxed  and  elongated. 

In  the  paralytic  cases  the  primary  changes  are  muscular;  the  action  of 
these  has  already  been  described. 

In  the  pathologic  and  traumatic  cases  the  changes  are  local  and  primarily 
osseous,  the  other  structures  becoming  subsequently  involved. 

Symptoms. — The  symptoms  of  genu  valgum  are  the  deformity  about 
the  knee,  the  peculiar  gait  in  walking,  and  the  secondary  deformities  which 
complicate  this  affection.  In  standing,  the  knees  are  more  or  less  unduly 
prominent  upon  the  inner  aspect,  the  leg  projects  outward,  and  the  feet  are 
separated  to  a  \-arying  degree.  The  in-knee  should  be  examined  in  the  fully 
extended  erect  position,  or,  better,  in  the  extended  recumbent  position.  Pre- 
ternatural lateral  mobility  of  the  articulation  is  characteristic.  Pain  on  the 
inner  side  is  not  constant,  but  when  present  suggests  a  local  inflammatory 


RICKETS;  KNOCK-KNEE ;  BOW-LEGS. 


731 


process.  Flexion  of  the  knee  causes  almost  entire  disappearance  of  the  angular 
deformity,  a  peculiarity  explained  by  two  factors:  the  obliquity  of  the  articular 
surface  of  the  condyles  and  consequent  oblique  axis  of  rotation,  as  in  a  Char- 
nier  joint  obliquely  placed;  and  also  the  outward  rotation  of  the  femur  upon 
its  own  axis.  A  simpler  and  more  satisfactory  explanation  is  found  in  the 
fact  that  the  increase  in  the  internal  condyle  is  only  in  length  and  not  antero- 


FiG.  549. — Tilting  of  Pelvis  prom  Inequality 
OF  Lower  Extremities  Due  to  Bow-legs 
(Spellissy). 


Fig.  550. — Same  Showing  Correction  of  Tilted 
Pelvis  (Spellissy). 


posteriorly,  and  that  in  flexion  the  facets  of  the  tibia  come  in  contact  with  the 
posterior  normal  condylar  surface. 

In  unOateral  cases  obliquity  of  the  pehds  downward  upon  the  affected 
side,  and  flexion  of  the  thigh  of  the  sound  side,  diminishes  the  inequality  of 
the  limbs  and  modifies  what  would  otherwise  be  a  limp. 

In  bUateral  cases  the  feet  are  widely  separated,  the  knees  slightly  flexed 


732  ORTHOPEDIC  SURGERY. 

to  prevent  them  from  striking,  and  with  each  step  the  knee  deformity  is 
increased,  producing  a  mild  half-jerking,  half-rolling  gait  that  is  characteristic. 
Flat-foot,  lateral  curvature,  hyperextension  of  the  knee  or  back-knee  are  asso- 
ciated as  secondary  or  coincident  deformities  dependent  upon  the  same  cause. 

In  rare  and  severe  cases,  in  persons  whose  muscles  are  not  weak,  a  com- 
pensatory supination  or  adduction  of  the  foot,  a  "toeing  in,"  may  develop, 
and,  notwithstanding  the  oblique  position  of  the  leg,  the  sole  may  be  set  flat 
upon  the  ground. 

In  single  knock-knee  a  compensatory  or  accommodative  bow-leg  of  the 
opposite  leg  may  occur.  Elaborate  methods  for  estimating  the  amount  of 
deformity  have  been  proposed  by  several  writers.  The  simplest  and  best 
method  of  recording  the  deformity  consists  in  making  an  outline  tracing  of 
both  limbs  with  the  patient  seated  with  the  limbs  extended  upon  a  sheet  of 
paper,  or  a  lead  tracing  of  the  inner  side  of  each  limb  may  be  made. 

Diagnosis. — The  diagnostic  points  have  already  been  given  under  the 
symptoms.  It  is  necessary  also  to  distinguish  the  varieties.  In  children  the 
majority  will  be  found  to  be  rachitic,  and  during  adolescence,  while  the  ma- 
jority are  statical,  the  rachitic  diathesis  may  often  be  discovered.  In  paralytic 
knock-knee  the  associated  nervous  lesions  distinguish  the  cause.  In  severe 
inflammatory  cases  the  local  symptoms  of  tumor  albus  will  distinguish,  and 
in  the  traumatic  cases  the  history  of  fracture  or  operation  and  the  osseous 
changes  will  render  the  diagnosis  clear. 

Prognosis. — Parents  are  frequently  assured  that  children  wUl  "grow  out  of" 
this  deformity,  but  such  is  the  truth  only  in  the  mild  degrees.  In  moderate 
and  severe  cases  the  probabilities  are  that  the  affection  will  remain  stationary 
or  grow  progressively  worse  unless  treated.  Robust  health,  strong  muscles, 
and  recovery  from  the  rachitic  diathesis  are  all  favorable  to  such  a  termina- 
tion, but  the  large  number  of  adults  seen  in  public  places  who  are  knock-kneed 
would  seem  to  prove  conclusively  that  many  never  recover. 

Since  the  introduction  of  aseptic  osteotomy  and  improved  forms  of  osteo- 
clasis, cases  requiring  operation  are  uniformly  successful.  In  arthritis  de- 
formans the  prognosis  is  unfavorable,  and  the  limb  may  become  useless. 

Treatment. — The  treatment  of  knock-knee  may  be  considered  under 
three  heads:   (i)  Hygienic;   (2)  Mechanical;   (3)  Operative. 

Hygienic  treatment.  The  hygienic  method  of  treatment  is  intended 
to  assist  Nature's  efforts  to  correct  the  deformity,  and  is  most  valuable  in 
infantile  rachitic  cases  and  in  statical  cases  occurrinsr  durino;  adolescence.     The 


RICKETS;   KNOCK-KNEE;   BOW-LEGS. 


733 


constitutional  treatment  for  rickets,  or  general  tonic  treatment,  should  be  begun, 
and  every  effort  should  be  made  to  improve  the  hygienic  surroundings  of  the 
patient.  General  gymnastic  treatment  is  of  the  highest  importance,  and  a 
change  to  seashore  or  mountain  air  will  often  work  marvels.  The  entire  lower 
extremities  should  be  rubbed  with  bathing  whisky,  and  manipulated  every 
night  before  retiring.  To  accomplish  the  most  good,  the  limb  should  be  grasped 
above  and  below  the  knee  and  the  thumbs  be  applied  upon  the  inner  side  of 
the  knee.  In  this  position  strong  traction  should  be  made  with  the  hands 
while  firm  pressure  is  exerted  upon  the  prominent  in-knee.  This  last  may 
be  applied  after  the  child  has  fallen  to  sleep.  The  pressure  should  be  firm, 
forcible,  repeated  several  times  for  a  few  seconds  each  time,  and  should  not 
be  severe  enough  to  awaken  the  child  or  make  it  cry.  This  manipulation  is 
of  the  greatest  value,  with  or 
without  the  use  of  apparatus. 
Mechanical  treatment. 
The  treatment  by  appara- 
tus is  employed  to  limit  the 
progress  of  the  deformity  by 
taking  the  weight  off  the  limbs, 
or  gradually  to  correct  the  de- 
formity by  making  counter- 
pressure  against  the  internal 
condyle.  Two  methods  are 
employed :  that  which  confines 
the  patient  to  bed,  and  that 

which  encourages  locomotion.  The  former  has  been  entirely  abandoned  in  this 
country.  Apparatus  is  employed  before  the  end  of  the  third  year,  when,  in 
rachitic  cases,  the  stage  of  hardening  usually  occurs,  though  cures  have  also 
been  effected  in  adolescents.  The  condition  of  the  bones  can  usually  be  deter- 
mined by  the  age,  and  also  by  the  elastic  or  springy  feel  when  gradual  manual 
pressure  is  applied.  In  cases  in  which  doubt  exists,  mechanical  treatment  can 
be  tried  for  several  months  before  resorting  to  operation.  Plaster-of-Paris 
furnishes  the  simplest  and  cheapest  mechanical  appliance. 

Some  employ  a  plaster  bandage  from  which  an  elliptic  piece  has  been 
removed  from  the  inner  side  of  the  knee,  and  with  a  splint  upon  the  outer  side 
make  traction.  Others  incorporate  metal  hinges  in  the  plaster  dressing,  and 
after  removing  a  section  from  the  outer  and  inner  sides  of  the  cast,  apply 


Fig.  551. — Manual  Coeeection  of  Knock-knee  (Hoffa). 


734 


ORTHOPEDIC  SURGERY. 


elastic  traction  by  means  of  rubber  bands.  These  cheap  methods  are  all  useful 
where  better  apparatus  cannot  be  secured,  and  have  been  referred  to  elsewhere, 
but  it  is  unnecessary  to  describe  the  various  forms  of  appliances  devised  for 
the  relief  of  this  deformity;  the  principle  of  all  is  identical,  the  application 
of  counter-pressure  upon  the  hypertrophied  internal  condyle,  but  they  differ 
in  the  method  of  application. 

The  retention  braces,  which  are  to  be  worn  during  the  day,  are  most 
effective.  They  consist  of  two  steel  uprights  carried  well  up  the  thigh, 
attached  by  a  stirrup  to  the  shoe  and  to  a  band  above  and  below  the  knee, 
jointed  at  the  knee  and  ankle  and  having  at  these  two  points  pressure-pads 
which  make  direct  pressure  against  a  long  rectangular 
counter-pressure  pad  attached  upon  the  outer  upright 
about  the  middle  of  the  leg.  They  must  be  fitted  to 
the  deformity  vsrith  bending  irons,  and  as  the  deformity 
diminishes  they  are  to  be  straightened  and  the  pressure 
increased.  These  braces  can  be  rendered  still  more 
efficient  by  fixing  the  knee-joint,  and  this  is  strongly 
to  be  recommended.  It  is  also  important  for  the  first 
three  months  to  wear  an  extension  connecting  the  leg 
braces  with  a  pelvic  girdle,  until  the  chUd  has  become 
accustomed  to  their  use,  since  fracture  of  the  thigh  has 
resulted  from  falls  caused  by  the  awkwardness  of  the 
braces. 

Manipulation  of  the  limb  as  described,  the  reten- 
tion day  brace,  and  the  elastic-traction  night  brace 
furnish  together  a  plan  of  treatment  that  has  proved 
very  curative  in  the  hands  of  the  writer. 
Operative  treatment.    The  surgical  procedures  now  employed  for  the 
relief  of  this  deformity  may  be  included  under  the  following  heads: 

1.  Tenotomy. 

2.  Forcible  manual  straightening. 

3.  Osteotomy. 

4.  Osteoclasis. 

I.  Tenotomy  of  the  biceps  and  division  of  the  Uiotibial  band  and  the 
external  lateral  ligament  have  been  performed  for  the  relief  of  this  affection. 
These  operations  are  now  employed  only  as  adjuncts  to  other  methods  in  para- 
lytic and  arthritic  cases. 


Fig.  552. — Lines  tor  Oste- 
otomy. 

I,  Mayer,  Billroth,  Schede;  2, 
Annandale;  3,  Ogston, 
Reeves,  Chiene;  4,  Mac- 
ewen;   5,  Taylor. 


RICKETS;   KNOCK-KNEE;   BOW-LEGS. 


735 


2.  Forcible  manual  straightening,  or  redressement  brusque,  proposed  by 
Delore  and  performed  by  many  European  surgeons,  and  designated  by 
Lorenz  epiphysiolysis,  has  not  been  favorably  received  in  this  country.  Delore 
has  recorded  one  death  from  scarlatina,  and  Tillaux  one  from  pyemia.  The 
operation  consists  in  forcible  manual  reduction  of  the  deformity,  the  limb 
being  bent  laterally  or  over-extended  until  it  snaps  and  gives  way;  the  lesions 
being  rupture  of  the  external  lateral  ligament,  separation  of  the  external  con- 
dyle, and  fracture  into  the  joint.     The  bad  results  of  the  operation  are  said 


Fig.  553.— Double  Knock-knee  before  Osteotomy  (Roberts).     Fig.  554.— Double  Knock-knee  after 

Operation  (Roberts). 


to  be  arthritis  with  effusion,  severe  periostitis,  and  necrosis,  and  a  weak  and 
lax  condition  of  the  joint.  The  operation  is  rough  and  unsurgical,  is  not 
entirely  safe,  and  should  be  abandoned  for  osteotomy  wherever  manual  correc- 
tion has  failed.  In  some  cases  of  severe  knock-knee,  in  the  stage  of  softening, 
rapid  manual  reduction  may  with  benefit  be  performed  without  the  occurrence 
of  any  of  the  lesions  before  referred  to. 

3.  Osteotomy.  Encouraged  by  the  antiseptic  method,  Annandale  in  1875 
excised  a  portion  of  the  condyles  for  genu  valgum,  and  in  the  same  ^ear 
aseptic  osteotomy  was  introduced  by  Volkmann,  for  ankylosis  of  the  knee. 


736 


ORTHOPEDIC  SURGERY 


In  1876  Ogston  operated  for  genu  varum  through  a  small  wound,  using 
a  saw,  and  was  followed  the  same  year  by  Schede. 

In  1878  Macewen  introduced  antiseptic  supracondyloid  osteotomy,  which 
removed  the  dangers  attendant  upon  opening  the  knee-joint,  which  had  been 
the  objection  in  all  previous  operations.  In  1879  Reeves  introduced  his  extra- 
articular condylotomy,  a  modification  of  Ogston's  operation,  the  object  of 
which  was  to  minimize  the  danger  of  opening  the  joint  and  to  loosen  and  prop- 
erly replace  the  displaced  condyle.    The  lines  of  the  different  operations  are 


Fig.  555. — Knock-knee  before  Osteotomy  (Roberts).       Fig.  556. — Same,  after  Osteotomy  (Roberts). 


given  in  Fig.  552.  The  superiority  of  the  Macewen  operation  is  admitted  by 
all,  and  except  in  rare  cases  it  is  now  performed  in  this  country  to  the  exclu- 
sion of  all  others. 

Of  the  different  operations  for  knock-knee  the  writer's  personal  prefer- 
ence is  for  that  of  Macewen,  and  this  and  its  modifications  are  all  that  will  be 
described. 

The  technic  of  osteotomy  in  general  has  already  been  described. 

The  Macewen  operation  is  performed  as  follows:  The  limb  having  been 
sterilized  at  the  point  of  election  for  the  introduction  of  the  osteotome,  the 


RICKETS:  KNOCK-KNEE;  BOW -LEGS. 


limb  is  flexed  and  placed  upon  a  sand-bag,  and  a  longitudinal  incision  is  made 
two  fingerbreadths  above  the  internal  condyle  of  the  femur  upon  the  inner 
aspect  of  the  thigh.  The  osteotome  is  introduced  down  to  the  bone,  tui-ned 
at  right  angles  to  the  long  axis  of  the  shaft,  and  with  a  few  blows  of  the  mallet 
the  bone  is  nearly  divided.  After  each  blow  the  osteotome  must  be  moved 
from  side  to  side  to  prevent  wedging,  and  the  deeper  layers  of  bone  should 
be  cut  in  a  fan-like  manner.  "WTien  the  section  is  nearly  completed,  as  indi- 
cated by  the  depth  to  which  the  chisel  has  disappeared,  the  instrument  is  with- 
drawn and  the  fracture  is  completed  with  the  hands.  The  limb  is  to  be  at 
once  set  in  a  slightly  over-corrected 
position,  a  sterile  dressing  is  ap- 
plied, and  the  limb  is  incased  in  a 
plaster-of-Paris  bandage  and  held 
in  the  corrected  position  until  it 
hardens.  The  dressing  need  not 
be  removed  for  three  weeks,  unless 
there  be  elevation  of  temperature, 
pain,  or  the  dressing  becomes  fetid. 
In  six  weeks  the  patient  may  be  per- 
mitted to  stand  with  the  casts  on,  or 
light  retention  braces  may  then  be 
fitted. 

Under  fuU  aseptic  precautions 
the  dangers  attending  the  operation 
are  slight. 

Hemorrhage  is  seldom  of  any 
moment,  but  the  anastomotica 
magna  has  been  wounded  and  the 

popliteal  has  required  ligation.     Fatal  hemorrhage  has  occurred,  and  amputa- 
tion for  gangrene  has  been  performed  by  Langton. 

As  compared  with  other  operations  of  the  same  character  and  magnitude, 
the  number  of  hemorrhages  has  been  very  few.  Thus,  in  525  operations 
by  Ogston's  method  there  were  thirteen  severe  hemorrhages,  while  in  580 
by  Macewen's  operation  there  were  only  two. 

These  accidents  occur  from  allowing  the  instrument  to  slip,  by  using  too 
broad  an  osteotome,  and  by  not  cutting  the  posterior  part  of  the  bone  with 
the  chisel  pointed  forward  and  outward,  but  allowing  the  chisel  to  point  back- 


FiG.  557. — Grattan  Osteoclast  Applied,  showing 
Method  of  Fracturing  or  Bending  Upper 
Third  oe  Tibia  (Blanchard). 


738 


ORTHOPEDIC  SURGERY 


ward.     Some  operators  prefer  to  perform  the  operation  upon  the  outer  side, 
and  Hahn  advocates  its  performance  on  both  the  outer  and  inner  side. 


o  o 
S  "o 

S    I 

3    _r 


111 


<  c  u 


When  the  deformity  lies  chief!}^  in  the  head  of  the  tibia,  osteotomy  of  this 
bone  is  a  rational  and  necessary  operation,  and  may  be  performed  as  follows: 
A   transverse  incision  one-half  inch  long  is  made  three-quarters  of  an  inch 


RICKETS;   KNOCK-KNEE;   BOW-LEGS.  739 

below  the  spine  of  the  tibia,  extending  through  the  skin  and  periosteum.  The 
outer  compact  portion  of  the  tibia  is  then  cut  transversely  and  the  bone  frac- 
tured. Wedge-shaped  sections  of  the  tibia  and  femur  are  seldom  necessary. 
If  the  fibula  cannot  be  fractured  by  manual  efforts,  it  should  be  divided  on 
the  same  plane  by  a  lateral  incision,  care  being  taken  to  avoid  wounding  the 
peroneal  nerve. 

4.  Osteoclasis,  or  forcible  fracture  of  bones  by  instrumental  means,  is 
said  to  have  been  practised  by  the  fathers  of  medicine,  and  has  again  recently 
been  advocated,  especially  by  the  French,  for  the  relief  of  genu  valgum. 

The  objections  to  the  method  are  the  splintering  of  the  fragments,  rup- 
ture of  the  ligaments,  and  separation  of  the  epiphysis.  The  more  recent 
instruments  of  French  make  are  said  to  have  overcome  these  objections  and 
to  be  capable  of  breaking  the  femur  within  two  fingerbreadths  of  the  joint 
without  affecting  the  articulation.  By  the  use  of  the  Grattan  osteoclast 
applied  in  some  instances  below  the  knee-joint  Blanchard  has  succeeded  in 
correcting  knock-knee  without  any  accidents  in  a  large  number  of  patients. 

Osteoclasis  is  more  applicable  to  the  shaft  of  the  bone,  as  in  the  correc- 
tion of  bow-legs,  and  is  slightly  more  safe  in  this  locality  than  osteotomy, 
whereas  osteotomy  is  considered  superior  for  the  correction  of  genu  valgum. 


Bow-legs. 

Bow-legs,  or  genu  varum,  is  that  deformity  in  which  the  knee  is  thrown 
outside  a  perpendicular  line  drawn  from  the  head  of  the  femur  to  midway- 
between  the  malleoli.  It  is  the  opposite  condition  to  knock-knee,  an  adduc- 
tion contracture. 

Synonyms. — English,  Bandy-legs;  Barrel-leg;  Saddle-leg.  German, 
Sabel-bein;  Sichel-bein;  0-bein.  French,  Genou  en  Dehors.  Latin,  Genu 
Extrorsum.  Greek,  Exogonyancon.  Italian,  Storto  di  gambe;  Lo  Strambio. 
Spanish,  Patizambo  (bandy-legged) ;  Pierna  Zamba ;  Zamba  de  piernas. 

Varieties. — It  is  generally  double,  but  may  be  single,  or  may  accompany 
konck-knee  of  the  opposite  side.  It  may  be  due  to  a  gradual  curvature  out- 
ward of  the  shafts  of  the  femur  and  tibia,  to  bowing  outward  of  the  lower  third 
of  the  tibia,  the  femur  remaining  normal,  or  both  bones  may  be  bent  forward 
and  outward.     The  knee  is  very  seldom  primarily  affected. 

Etiology. — It  occurs  in  children  about  the  time  of  walking,  and  is  almost 
without    exception    rachitic    in    origin.     The  chief  factor    in    producing    the 


740 


ORTHOPEDIC  SURiiERV 


deformity  is  the  boch'-wcight  in  standing  and  walking.  ]\Iuscular  action  is  a 
factor  in  some  children  who  have  never  walked,  but  it  cannot  be  accepted  as 
the  chief  cause,  as  has  been  asserted.  The  direction  in  which  the  bones  yield 
to  the  superincumbent  weight  of  the  body  will  depend  upon  the  direction  in 
which  the  pressure  is  transmitted,  the  weak  part  of  the  bone  normally,  and 
the  location  of  the  rachitic  softening. 

In  children  who  have  not  walked,  the  bowing  of  the  tibia  outward  may 
be  accounted  for  by  the  tailor  fashion  of  sitting  assumed  by  small  children. 

Children  affected  with  rickets  stand  with  the 
thighs  flexed,  the  feet  wide  apart,  and  the  lumbar 
spine  arched  forward,  this  position  being  assumed 
on  account  of  muscular  weakness,  or  more  probably 
on  account  of  the  pendulous  and  weighty  abdomen. 
In  this  position  the  line  of  gravity  falls  outside  the 
knee-joint,  the  shafts  of  the  long  bones  yield  to  the 
pressure,  and  in  time  the  internal  condyle  atrophies 
and  the  outer  one  hypertrophies.  In  some  cases  the 
bowing  is  extreme  and  the  outline  of  the  legs  is  almost 
circular. 

Symptoms. — These  are  principally  the  de- 
formity of  the  legs,  the  diminished  height,  and  the 
peculiar  waddling  gait  in  walking. 

In  cases  where  bow-legs  and  knock-knee  coexist 
on  opposite  sides  the  bow-leg  is  always  the  more 
secure.  The  feet  are  usually  inverted,  in  an  instinc- 
tive effort  to  contract  the  base  of  support,  and  favor 
progression. 

Diagnosis. — The  condition  is  clear  upon  in- 
spection, but  it  is  always  necessary  to  determine  also  the  location  and  degree  of 
bowing,  and  the  condition  of  the  bones. 

The  only  afi'ection  which  it  resembles  is  congenital  dislocation  of  the  hip, 
and  the  differential  diagnosis  from  this  has  already  been  pointed  out.  The 
presence  or  absence  of  coxa  vara  should  also  be  noted,  since  this  condition 
may  simulate  bow-legs. 

Prognosis. — The  prospects  of  spontaneous  outgrowth  of  this  deformity 
are  more  favorable  than  in  knock-knee,  but  the  fact  that  bow-legs  are  met 
with  among  adults  proves  that  some  cases  never  entirely  recover.     When  the 


Fig.  561. — Bow-legs  Brace. 


Fig.  562. — Skiagraph.     Bow-legs  after  Osteotomy.     One  or  Author's  Cases. 


RICKETS;  KNOCK-KNEE;   BOW-LEGS. 


743 


bones  harden  in  this  deformed  position,  recovery  without  mechanical  treat- 
ment or  operation  is  not  to  be  expected. 


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Treatment. — The  treatment  of  knock-knee  may  be  included  under  three 
heads:    (i)  Hygienic;    (2)  Mechanical;   and  (3)  Operative. 

The  hygienic  plan  of  treatment  includes  the  correction  of  the  rachitic 


744  ORTHOPEDIC  SURGERY. 

diathesis  b}^  proper  medication  and  improved  hygiene,  daily  rubbing  of  the 
limbs,  and  manipulation  of  the  deformity  with  the  hands,  grasping  the  limb 
with  the  hands  upon  the  outer  side  and  applying  pressure  in  such  a  manner 
as  gradually  to  reduce  the  deformity. 

The  mechanical  treatment  is  to  be  conducted  upon  the  same  general  prin- 
ciples as  knock-knee.  In  most  cases  the  leg-brace  before  described,  but  with 
the  pressure-pads  differently  located,  and  with  the  addition  of  a  special  pres- 
sure device  over  the  outer  side  of  the  leg,  answers  well  as  a  retention  and  walk- 
ing brace.  The  pads  are  applied  to  the  inner  anlde  and  inner  side  of  the  knee, 
and  the  uprights  between  the  knee  and  ankle  are  hinged  on  the  outer  side 
to  the  oval  pressure  pad,  while  the  inner  upright  has  an  adjustable  slide  which 
allows  of  extension  as  the  leg  is  straightened.  Mechanical  treatment  is  not 
of  service  after  the  bones  have  hardened,  and  are  useless  usually  after  the  age 
of  three  and  one-half  to  four  years.  Careful  tracings  from  time  to  time  will 
indicate  the  progress  of  the  case. 

The  operative  treatment  of  bow-legs  includes:  (i)  Osteotomy,  and  (2) 
Osteoclasis. 

Osteotomy  is  the  operation  usually  performed  by  American  surgeons, 
although  the  results  of  osteoclasis  are  more  favorable  in  bow-legs  than  in 
knock-knee,  and  the  same  dangers  are  not  to  be  feared.  Osteotomy  for  bow- 
legs is  performed  in  a  similar  manner  to  that  for  knock-knee,  and  several  sec- 
tions of  the  bone  may  be  required,  as  high  as  six  and  even  ten  osteotomies 
having  been  performed  at  one  time,  these  sections  being  made  wherever  they 
appear  most  necessary.  In  many  section  of  the  upper  part  of  the  tibia  will 
give  the  best  results.  In  performing  this  operation  great  care  should  be  exer- 
cised to  avoid  wounding  the  anterior  tibial  in  front,  and  the  posterior  behind, 
and  if  the  fibula  require  division  on  the  same  level  the  peroneal  nerve  is  in 
danger.  The  same  rules  and  technic  should  be  observed  as  in  operations 
for  knock-knee.  As  a  rule,  in  osteotomy  for  bow-legs,  simple  linear  osteotomy 
win  be  all  that  is  required,  and  removal  of  a  wedge  of  bone  will  be  required 
only  in  the  most  exceptional  cases.  If  the  fragments  override,  a  subcutaneous 
section  of  the  tendo  Achillis  will  usually  correct  it. 

Osteoclasis  is  most  efficient  in  outward  bowing  of  the  femur  and  tibia, 
since  the  sharp  edge  of  the  tibia  offers  a  disadvantage  to  its  application  in  an- 
terior bowing  of  the  leg.  It  is  not  applicable  in  adults  nor  where  the  bones 
are  very  strong.  The  fracture  with  the  osteoclast  is  a  transverse  one  with- 
out  splintering,  and  will   usually  be   found   to   occur  opposite  to   the  screw- 


RICKETS;  KNOCK-KNEE ;  BOW-LEGS.  745 

pad  plate.  Blanchard  has  performed  osteoclasis  upward  of  seven  hundred 
times  for  rachitic  deformities  without  an  accident.  The  great  danger  in  osteo- 
clasis is  "delay  in  releasing  the  machine  after  the  fracture  has  been  made.  The 
pressure  should  only  be  momentary. 

After  correction  the  deformity  should  be  slightly  over-corrected. 

Anterior  bow-legs  consists  of  a  long  gradual  curve  from  the  knee  to  the 
ankle,  or  an  abrupt  angular  curve  in  any  portion  of  the  bone,  but  usually  in  the 
lower  third.  It  is  produced  by  sitting  constantly  with  one  leg  resting  upon  the 
other,  or  by  the  weight  of  the  body  falling  upon  the  leg  with  the  knee  bent. 

The  course,  symptoms,  and  diagnosis  are  the  same  as  in  other  rachitic 
curves.  When  severe,  the  bending  of  the  tibia  may  be  mistaken  for  arthritis 
deformans  syphilitica,  as  both  diseases  may  occur  about  the  same  age.  The 
unilateral  distribution  of  the  latter  affection,  together  with  the  absence  of  other 
rachitic  symptoms,  will  serve  to  distinguish  it.  The  prognosis  is  not  so  favor- 
able as  in  knock-knee  and  bow-legs,  the  mechanical  conditions  being  entirely 
different.  The  treatment  may  be  mechanical  or  operative.  In  the  early  stages, 
before  the  third  year,  much  may  be  accomplished  by  manual  straightening 
and  the  use  of  pressure  apparatus,  but  all  orthopedic  writers  agree  that  after 
once  the  bone  has  hardened  anterior  ciirves  of  any  magnitude  cannot  be 
reduced  by  apparatus. 

The  form  of  apparatus  employed  during  the  early  stages  consists  of  lateral 
steel  uprights  attached  by  a  stirrup  to  the  shoe  below,  secured  to  the  leg  above 
by  a  leather  band,  and  making  pressure  over  the  curve  in  front  by  means  of 
a  broad  leather  strap  or  pad  connected  with  the  steel  uprights. 

The  operative  procedures  include  forcible  fractures,  osteoclasis,  and 
osteotomy. 

Forcible  fracture  in  children  under  three  years  of  age  is  safe  and  efficient, 
both  bones  being  fractured  by  the  hands,  a  roller  bandage,  a  sand-bag,  or  the 
knee  of  the  operator  being  used  as  a  fulcrum.  After  correction  the  limb  should 
be  secured  in  a  plaster-of- Paris  dressing. 

Osteoclasis  offers  the  advantage  over  manual  correction  that  pressure  can  be 
applied  to  a  definite  point,  but  in  this  locality  is  less  subject  to  the  objections 
already  detailed. 

Osteotomy  gives  uniformly  excellent  and  speedy  results.  In  deformities 
of  moderate  degrees  simple  linear  osteotomy  with  a  chisel  is  efficient,  but  in 
the  severer  grades  cuneiform  osteotomy,  or  removal  of  a  wedge-shaped  piece 
of  bone,  is  necessarv. 


746  ORTHOPEDIC  SURGERY. 

Simple  linear  osteotomy  is  performed  as  already  described.  In  perform- 
ing cuneiform  osteotomy  the  most  rigid  asepsis  must  be  enforced. 

To  determine  the  amount  of  wedge  to  be  removed,  the  sphenometer  may 
be  used,  or,  what  most  surgeons  prefer,  a  paper  outline  of  the  anterior  aspect 
of  the  leg  may  be  drawn  and  cut  out.  This,  when  cut  through  the  point  of 
curvature  and  straightened,  will  give  the  size  of  the  wedge. 

The  fibula,  if  rigid  and  strong,  should  first  be  divided.  The  section  in 
the  tibia  with  the  chisel  should  extend  two-thirds  through,  and  the  wedge  should 
be  taken  away  by  a  series  of  chippings,  and  the  bone  finally  fractured  by  man- 
ual force.  This  is  necessary  on  account  of  the  close  proximity  of  the  posterior 
tibial  artery  and  vein,  Dandridge  having  lost  a  patient  from  pyemia  following 
an  injiiry  of  these  vessels. 

Tenotomy  of  the  tendo  Achillis  is  required  in  almost  all  cases.  Drain- 
age with  sterilized  catgut  or  horsehair  is  necessary,  and  full  sterile  dressing  and 
a  plaster-of-Paris  cast  should  be  employed. 


CHAPTER  XXVI. 
OTHER  DEFORMING  DISEASES  OF  THE  BONES. 

Tardy  Hereditary  Syphilis  of  the  Bones. 

The  deformities  resulting  from  hereditary  syphilis  were  entirely  over- 
looked until  Hutchinson  and  Fournier  called  particular  attention  to  them. 
Since  then  Hoffa  has  referred  to  syphilitic  deforming  osteitis  of  the  lower 
extremity,  and  others  have  reported  cases  of  tardy  hereditary  syphilis  of 
the  bones. 

This  is  a  disease  of  the  bones  producing  at  times  considerable  deformity 
and  accompanied  with  constitutional  disturbance,  but  which  is  often  suffered 
to  pass  unrecognized.  It  cannot  be  a  very  rare  affection,  for  in  the  past  ten 
years  at  least  twenty  cases  have  come  under  my  notice. 

Synonyms. — French,  SyphUis  Hereditaire  Tardive.  German,  Osteitis 
Deformans  Syphilitica.  Italian,  Ostiti  eredetaria  sifilitica.  Spanish,  Ostitis 
hereditaria  si&litica. 

When  tardy  hereditary  syphilis  affects  the  bones,  it  is  most  apt  to  do  so 
between  the  ages  of  six  and  ten  years,  although  cases  do  occur  as  early  as  two, 
and  even  in  adults.  In  its  commencement  the  affection  is  apt  to  be  regarded 
as  rheumatic  because  of  the  pains;  these  may  be  located  either  in  the  shaft 
of  the  bones  or  in  the  neighborhood  of  the  articulations.  They  may  be  very 
severe  and  worse  at  night  and  after  use  of  the  limb,  preventing  the  patient 
from  sleeping.  In  some  cases  they  vary  in  severity  with  the  state  of  the  weather. 
In  cases  in  which  the  disease  is  active  marked  changes  of  temperature  are 
observed,  whUe,  when  it  is  chronic  or  subacute,  it  may  be  only  slightly  ele- 
vated or  not  at  all.  In  very  acute  cases  the  temperature  may  rise  very  high. 
It  only  occasionally  shows  the  marked  rise  and  fall  seen  in  septic  diseases, 
and  then  only  for  a  day  or  two  at  a  time.  Usually  it  resembles  more  that  of 
t3^hoid  fever,  having  a  daily  variation  of  from  one  to  three  degrees.  Chills 
are  not  present.  After  the  disease  has  existed  for  a  variable  period  of  time 
enlargement  of  the  bones  is  observed.  This  may  occur  either  regularly  around 
the  bone  or  localized  more  to  one  side.     In  the  tibia  it  is  usually  in  a  forward 

747 


74S 


ORTHOPEDIC  SURGERY 


direction,  causing  it  to  project  in  a  peculiar  manner  and  forming  the  saber- 
bladed  deformity  of  Fournier.     The  surface  of  the  bone  is  also  irregularly 

enlarged  in  the  form  of  nodes,  showing  the 
presence  of  periostitis  a.s  well  as  osteitis. 

When  the  affected  bony  surface  is  sub- 
cutaneous and  the  process  active,  the  skin 
assumes  a  dusky  red  color,  fluctuation  and 
perforation  occur,  and  a  scale  of  bone  is 
cast  off.  This  exfoliation  may  consist  of  a 
few  calcareous  granules  or  of  a  large  scale, 
or,  if  the  process  is  exceptionally  severe, 
may  involve  a  considerable  portion  of  the 
shaft  itself.  The  tibia  is  the  bone  most 
frequently  affected,  but  I  have  seen  the 
fibula  and  radius  also  attacked.  Pains 
have  also  been  complained  of  by  the 
patients  in  other  parts  of  the  skeleton, 
which  would  indicate  that  they  too  were 
affected.  In  examining  into  the  history  of 
these  cases  sometimes  other  manifestations 
of  the  syphilitic  disease  are  discovered,  such 
as  imperfections  of  the  teeth ;  these  are  not 
so  apt  to  be  notched  as  pegged  and  decayed. 
Evidences  of  old  e3fe-trouble,  keratitis,  etc., 
deafness,  snuffles,  and  eruptions  in  infancy, 
and  general  malnutrition  may  also  at  one 
time  have  been  present.  The  history  of 
the  parents  and  brothers  and  sisters  usually 
yields  confirmatory  facts,  the  infant  mor- 
tality being  great,  and  miscarriages  not  un- 
common; hydrocephalus  may  also  occur. 
The  course  of  the  disease  is  essentiaUy 
chronic.  Remissions  occur  only  to  be  suc- 
ceeded by  a  reappearance  of  the  symptoms. 
Suppuration  and  e.xfoliation  of  bone  are  followed  by  healing  with  disfiguring 
scars.  The  swellings  not  infrequently  disappear  without  leaving  any  trace  of 
their  presence. 


Fig.   566. — Saber-bladed   Deformity   of 
Tibia  from  Syphilis. 


OTHER  DEFORMING  DISEASES  OF  THE  BONES.  749 

The  disease  does  not  tend  to  a  fatal  issue,  but  exists  in  a  more  or  less  active 
state  for  four  to  eight  or  more  years.  When  the  tibia  is  affected  near  its  epiphyses, 
its  growth  is  accelerated  and  it  becomes  longer  than  the  fibula,  thus  throwing 
the  foot  outward  in  the  position  of  the  valgus;  and  when  the  radius  is  affected, 
the  hand  may  be  pushed  toward  the  ulnar  side. 

As  regards  internal  medication,  iodid  of  potassium  in  as  large  doses  as 
the  patient  will  bear  for  long  periods  of  time  should  be  tried,  to  be  alternated 
with  mercurials,  tincture  of  iron,  syrup  of  the  hypophosphites,  syrup  of  the 
iodid  of  iron,  cod-liver  oil,  and  other  alterative  and  tonic  remedies.  By  these 
measures  the  disease  may  be  arrested. 

The  tendency  to  valgus  should  be  corrected  by  an  ankle  brace  with  a  pad 
at  the  inner  ankle,  and  a  leather  strap  over  the  greatest  prominence  of  the 
deformity.  Any  increase  in  the  lengths  of  the  limbs  should  be  equalized  by  an 
elevated  sole  upon  the  shoe  of  the  sound  side. 

As  long  as  the  disease  is  active  operative  treatment  must  be  delayed.  Sub- 
sequently an  osteotomy,  simple  or  cvmeiform  in  character,  should  be  performed, 
after  which  a  brace  should  be  worn  for  a  time. 

Osteomalacia. 

Osteomalacia  is  an  inflammatory  process  of  the  bones  characterized  by  the 
absorption  of  the  lime  salts,  softening,  and  deformity.  It  is  also  known  as 
mollitis  ossium.  It  resembles  rickets,  but  the  process  begins  in  the  medulla 
and  extends  outward,  the  periosteum  being  h3rpertrophied  later.  The  affection 
has  been  observed  from  birth,  an  example  of  which  has  been  illustrated  in 
Part  I.  Instances  occurring  during  childhood  have  been  recorded,  but  it  is 
most  prevalent  during  adult  life.  Females  suffer  more  frequently  than  males, 
a  fact  attributed  to  parturition.  The  puerperal  form  has  its  origin  in  the  pelvis, 
whence  it  may  extend  to  other  parts. 

The  etiology  of  this  disease  is  still  in  doubt.  The  treatment  consists  in  sup- 
porting the  deformed  bones  by  apparatus,  and  where  the  deformity  is  excessive, 
in  correcting  the  angular  bending  of  the  long  bones  by  osteotomy.  After 
operation  apparatus  must  be  worn  continuously  as  long  as  the  condition  exists. 
It  has  been  observed  by  the  writer  that  greater  care  must  be  observed  to  main- 
tain a  corrected  position  for  the  fragments  after  osteotomy,  and  sometimes 
wiring  is  absolutely  necessary,  especially  in  the  femur. 


750  ORTHOPEDIC  SURGERY. 

Osteitis  Deformans. 

Synonyms. — English,  Paget's  disease.  German,  Osteomalacia  chronica 
deformans  hypertrophica;  Paget'sche  Krankheit. 

Since  attention  was  first  called  to  this  disease  by  Paget  in  1877  numerous 
examples  have  been  observed,  and  Packard,  Steel,  and  Kirkbride  have  recorded 
sixty-seven  instances,  the  majority  of  which  occurred  in  males. 

The  disease  is  a  chronic  inflammatory  process  affecting  the  bones,  sym- 
metric in  distribution,  and  characterized  by  hypertrophy,  softening,  and  de- 
formity. 

Etiology. — Nothing  definite  is  known  as  to  the  cause  or  nature  of  this  dis- 
ease, but  its  association  with  arthritis  deformans  has  led  to  the  assertion  that 
they  are  pathologically  identical,  while  the  enlargement  of  the  skull  relates  it  in 
some  obscure  manner  with  acromegaly. 

Symptoms. — The  affection  may  begin  abruptly,  but  usually  there  is  an  in- 
cipient stage  of  periosteal  pain,  headache,  etc.,  preceding  the  bone  inflammation. 
The  general  constitutional  symptoms  are  not  striking.  Kyphosis  is  present,  the 
head  is  held  forward  with  drooping  of  the  shoulders,  and  there  is  a  stiff,  clumsy 
gait.  The  skull  is  enlarged,  the  long  bones  are  hypertrophied,  and  the  ex- 
tremities are  bowed  at  the  knees.     The  distribution  of  the  deformity  is  bilateral. 

The  course  of  the  affection  is  slow  and  progressive,  and  there  is  no  known 
treatment  which  will  arrest  the  progress  of  the  disease. 

Secondary  Hypertrophic  Osteo-arthropathy. 

The  deformity  of  the  extremities  which  occurs  secondary  to  chronic  pul- 
monary affections  is  interesting  to  the  orthopedic  surgeon  on  account  of  the  dif- 
ferential diagnosis. 

Since  the  disease  was  first  described  by  Marie  in  1890  numerous  cases  have 
been  observed.  The  condition  is  an  inflammatory  lesion  of  the  osseous  structures 
and  is  characterized  by  clubbing  of  the  fingers  and  enlargement  of  the  distal 
extremities  of  the  tibia  and  fibula,  and  the  metatarsal  and  phalangeal  bones  in 
the  feet,  and  of  the  distal  extremities  of  the  radius  and  ulna,  and  metacarpal 
and  phalangeal  bones  in  the  hands.  The  osseous  deposit  is  most  marked  be- 
neath the  periosteum.  The  skull  is  not  affected  and  the  lesion  of  the  extremities 
is  largely  due  to  the  impairment  in  the  circulation.  The  affection  is  uncommon 
in  childhood. 

This  disease  might  be  confused  with  acromegaly,  and  for  this  reason  this 
latter  condition  deserves  consideration  here.     In  acromegaly  enlargement  of 


OTHER  DEFORMING  DISEASES  OF  THE  BONES.  751 

the  hands  and  feet  is  associated  with  enlargement  of  the  face.  It  usually  occurs 
among  men  of  gigantic  size.  The  characteristics  which  distinguish  this  affection 
are  that  the  enlargement  of  the  extremities  involves  all  the  tissues  and  is  not 
confined  to  the  bone.  The  enlargement  does  not  affect  the  shafts  of  the  bones, 
and  the  head  is  frequently  involved,  the  enlargement  including  the  face,  and 
not  being  confined  to  the  skull. 

In  secondary  hypertrophic  osteo-arthropathy  the  course  of  the  disease 
is  progressively  worse,  except  in  rare  instances  when  recovery  has  been 
observed. 

Arthritis  Deformans. 

A  chronic  disease  of  the  joints  characterized  by  great  deformity  following 
changes  in  the  bone,  cartilage,  and  synovial  membrane,  with  peri-articular 
formation  of  new  bone. 

The  existence  of  these  affections  among  the  ancients  is  attested  by  the 
evidences  found  by  Chiase  in  the  bones  unearthed  at  Pompeii,  in  an  Egyptian 
skeleton  of  the  Ptolemaic  period,  in  the  Roman  skeleton  found  in  a  sarcophagus 
at  Smithfield,  England,  and  in  the  skeleton  of  the  Norse  viking  which  was  found 
entombed  in  his  warship,  in  the  Christiania  Fjord. 

Synonyms. — English,  Rheumatoid  Arthritis;  Osteoarthritis;  Arthritis 
Chronica  Ulcerosa  Sicca;  Nodular  Rheumatism;  Chronic  Articular  Rheuma- 
tism; Chronic  Rheumatic  Arthritis;  Rheumatic  Gout;  Dry  or  Proliferating 
Arthritis;  Nodosity  of  the  Joints;  Chronic  Rheumatoid  Arthritis  of  the  Hip. 
French,  Rheumatisme  noneax;  Rheumatisme  chronique  primitif.  Italian,  Artriti 
reumatoida.     Spanish,   Artritis  reumatoida. 

Etiology. — The  true  nature  of  this  disease  is  very  obscure.  It  has  been 
ascribed  to  rheumatism  or  gout;  to  exposure  or  traumatism;  injury  seems  to 
play  some  part  in  its  causation,  as  it  is  often  found  following  fracture  of  the 
hip-joint.  Recent  authorities  are  inclined  to  consider  arthritis  deformans 
among  the  arthropathies  of  spinal  cord  origin  similar  to  the  joint  lesions  of 
syringomyelia  and  tabes.  The  nervous  element  is  still  in  doubt,  however, 
although  articles  have  been  contributed  by  Hektoen,  Mitchell,  Latham,  and 
others  in  support  of  this  view.  Schiiller  describes  a  bacillus  found  in  the  joints 
of  arthritis  deformans,  with  which  he  has  been  able  to  produce,  experimentally, 
similar  processes  in  the  joints  of  animals.  Dor  produced  similar  changes  in 
the  joints  of  animals  by  the  injection  of  attenuated  cultures  of  staphylococcus. 
Two  forms  of  the  disease  are  recognized:    (i)  Osteoarthritis,  a  polyarticular 


752 


ORTHOPEDIC  SURGERY 


form  occurring  in  ad\-anced  life,  in  which  marked  hypertrophic  changes  are 
present  in  the  articular  surfaces,  consisting  of  bony  formations,  primarily  involv- 
ing the  articulation  and  leading 
to  marked  enlargement  of  the 


Fig.    567. — Rheumatoid     Arthritis     (Specimen,    Wistar 
Institute  of  Anatomy). 


Fig.  56S.— Rhizomelic  Spondylitis. 


joint,  distortion,  and  ankylosis;  and  (2)  rheumatoid  arthritis,  a  polyarticular  form 
occurring  in  childhood  or  early  adult  life,  in  which  there  is  primary  disease  of 


OTHER  DEFORMING  DISEASES  OF  TFIE  BONES. 


(53 


the  soft  parts  of  the  joint,  and  is  not 
but  frequently  results  in  true  an- 
kylosis. Another  form  has  been 
described  by  Marie  as  rhizomelic 
spondylosis,  from  its  derivation — 
relating  or  affecting  the  roots  of 
members — in  which  ankylosis  of 
the  vertebras  is  associated  with 
ankylosis  of  the  hips  and  shoul- 
ders. The  affection  does  not  other- 
wise differ  from  the  adult  variety. 
Pathology. — The  pathologic 
changes  in  the  hypertrophic  form 
begin  with  thickening  of  the  syno- 
vial membrane,  with  h3^ertrophy 


followed  by  marked  bony  enlargement 


Fig.  569. — Rheumatoid  Arthritis  of  Knee.  Fig.  570. — False  Ankylosis  feom  Chronic  Rhed- 

MATOiD  Arthritis. 


of  its  fringes,  tHe  branching  appearance  of  which  has  given  rise  to  the  name  of 
lipoma  arborescens. 


.754 


ORTHOPEDIC  SURGERY 


The  cartilage  disintegrates,  presenting  a  yellow  shreddy  appearance,  and 
finally  is  absorbed  or  gradually  thinned  by  attrition,  thus  laying  bare  the  ends  of 
the  bone,  which  become  smooth,  polished,  and  eburnated.  The  head  of  the 
bone  may  be  locked  in  a  splint  of  osteophytes  which  form  from  the  proliferated 
cells;  or,  denuded  of  its  cartilage,  may  undergo  an  ivory-like  condensation  (ebur- 
nated layer)  with  final  atrophy,  exposing  the  Haversian  canals  and  presenting  a 
worm-eaten  appearance.     The  muscles  around  the  joint  become  wasted,  the  lig- 


FiG.  571. — Rheumatoid  Arthritis.     Specimen. 


Fig.  572. — Rheum.vtoid  Arthritis.    Specimen. 


aments  greatly  thickened,  which,  together  with  the  osteophytes,  often  form  a  false 
ankylosis  of  the  joint. 

The  form  found  in  childhood  and  early  adult  life  is  characterized  by  marked 
inflammatory  changes  beginning  in  the  synovial  membrane  and  soft  parts, 
with  resulting  hypertrophy  of  the  synovial  villi  and  effusion.  The  cartilages 
become  eroded,  but  are  not  destroyed,  and  the  erosion  is  riot  followed  by 
hypertrophy  of  the  ends  of  the  bones.     Later  atrophy  of  the  synovial  membrane 


OTHER  DEFORMING  DISEASES  OF  THE  BONES. 


755 


occurs,  accompanied  by  the  formation  of  fibrous  tissue  and  resulting  ankylosis. 
Schliller  describes  the  two  forms  under  the  terms  polyarthritis  villosa  hyper- 
plastica  and  polyarthritis  villosa  ankylopoetica. 

Symptoms. — In  its  acute  form  this  disease  resembles  articular  rheumatism. 
If,  as  is  more  usual,  it  begins  in  its  chronic  form,  the  first  symptom  is  pain  on 
motion,  stiffness  and  swelling  of  the  joint.  From  involvement  of  one  joint 
the  disease  may  spread  until  nearly  all  of  the  articulations  of  the  body  are  affected. 
The  amount  of  pain  and  of  the  effusion  into  the 
joint  varies  greatly.  The  shape  of  the  joint  is 
permanently  altered  by  the  deposition  of  new 


Fig.    573. OSTEO-ARTHRITIS    OF    THE    KnEE-JOINT. 


Fig.  574. — Chronic   Rheusiatoid 
Arthritis  in  Child. 


bone,  by  the  thickening  of  ligaments,  and  atrophy  and  retraction  of  the  muscles. 
A  peculiar  crepitation  produced  by  the  friction  of  roughened  synovial  membrane 
is  recognizable.  Motion  may  be  entirely  lost,  either  from  muscular  spasm  or 
from  the  splint  of  osteophytes. 

In  the  femur,  from  atrophy  of  the  neck,  the  trochanter  may  be  found 
above  Nelaton's  line.  Heberden's  nodosities  is  a  variety  of  this  disc:''. 50  in 
which  little  nodules  develop  upon  the  sides  of  the  distal  phalanges. 


756 


ORTHOPEDIC  SURGERY. 


In  childhood,  in  addition  to  the  periarticular  changes  already  noted, 
there  are  associated  extreme  muscular  atrophy,  lymphatic  enlargements 
of  the  axUlary  and  inguinal  glands,  with  hyper- 
trophy of  the  spleen  and  liver.  Deformity  is 
great  and  ankylosis  often  results.  The  disease 
is  sometimes  spoken  of  as  Still's  disease,  from 
its  discoverer. 


Fig.  575- — Photograph  of  Specimen  of  Spondylitis  Deformans, 
SHOWING  Deposits  (from  the  Museum  of  the  Philadelphia  Hos- 
pital). 


Fig.  576. — Chkonic  Rheum.\- 
toid  Arthritis,  with  Lat- 
er.\l  Curvature  and  En- 
largement OF  the  Aceta- 
BULA  and  Heads  of  Femur. 


Spondylitis  Deformans,  or  Rheumatism  of  the  Spine. 

A  primary  ankylosing  arthritis  of  the  vertebral  column  is  a  complication  of 
arthritis  deformans  as  it  occasionally  is  of  gonorrheal  rheumatism.     It  presents, 


OTHER  DEFORMING  DISEASES  OF  THE  BONES.  Ibl 

as  its  characteristic  symptom,  marked  stiffness  of  tiie  spine;  indeed,  the  whole 
vertebral  column  may  be  as  rigid  as  an  iron  rod.  Paroxysmal  pain  aggravated 
by  every  jar  is  present.  The  normal  curves  are  exaggerated,  especially  the  lum- 
bar and  dorsal  ones,  so  that  the  patient  may  walk  as  though  bent  with  Pott's 
disease.  The  cervical  vertebras  are  the  last  to  become  involved.  In  that 
case  the  up-and-down  movements  of  the  head  are  lost,  though  rotation  is  stUl 
possible.  In  severe  cases  the  ankylosis  of  the  ribs  with  the  spine  is  so  complete 
that  chest  expansion  is  almost  abolished,  the  breathing  being  entirely  abdominal. 
Its  course  is  chronic  in  the  extreme;  the  bone  inflammation,  having  no  destruc- 
tive tendency,  accomplishes  nothing  more  than  stiffening  of  the  column. 

Diagnosis. — The  diagnosis  in  the  senile  or  hypertrophic  form  depends 
upon  the  age,  the  polyarticular  involvement,  the  slowly  increasing  deformity, 
the  marked  increase  in  size  of  the  affected  joints,  the  presence  of  the  ecchon- 
droses  and  Heberden's  nodosities. 

In  the  juvenile  or  atrophic  form  the  history  of  injury,  the  polyarticular 
involvement,  the  marked  deformities  and  resulting  ankylosis  wUl  aid  in  making 
a  diagnosis.  Its  course  is  rather  rapid,  the  process  of  deformity  developing 
in  one  or  two  years  after  the  injury,  accompanied  by  pain  and  impairment 
of  motion,  until  walking  is  difficult  and  finally  ankylosis  occurs. 

Treatment. — The  pain  and  irritation  of  the  acute  attack  are  relieved  by 
rest  in  bed,  with  more  perfect  rest  of  the  joint  by  the  use  of  a  traction  splint. 
Counter-irritation  by  means  of  the  Paquelin  cautery,  blisters,  or  iodin  is  of 
value  in  meeting  this  indication,  as  is  the  use  of  hot  or  cold  douching.  In 
spondylitis  deformans  a  posterior  spinal  splint  is  of  service,  and  when 
the  cervical  vertebras  are  involved  an  antero-posterior  head  support  with  a 
chin-rest. 

The  disease  is  an  incurable  one,  but  its  progress  may  be  arrested  by  a  visit 
to  some  of  the  numerous  foreign  or  domestic  mineral  springs:  Carlsbad,  Baden, 
or  Vichy;  Buxton,  Harrogate,  or  Bath  in  England,  or  Richfield,  Sharon,  or 
Arkansas  Hot  Springs  in  our  own  country.  Water  from  the  Veronica  sprmg 
in  California  is  highly  recommended.  The  general  health  must  be  maintained 
by  tonics,  good  food,  and  fresh  air.  The  diet  should  be  carefully  regulated  and 
fatigue  and  over-exertion  prevented.  Internal  remedies,  as  salicylic  acid,  arsenic, 
potassium  iodid,  salophen,  and  cod-live/  oU  produce  no  appreciable  change 
in  the  condition.  Massage  may  help  to  promote  the  absorption  of  the  effusion 
and  to  restore  mobility  and  maintain  the  nutrition  of  the  muscles,  but  passive 
movements  are  to  be  avoided,  as  increasing  the  amount  and  degree  of  ankylosis. 


758  ORTHOPEDIC  SURGERY. 

In  senile  coxitis  a  protection  traction  hip-splint  will  be  of  service,  and 
crutches  and  canes  are  often  useful. 

In  the  late  stages  of  ankylosis  with  deformity  some  good  can  be  effected 
by  surgical  means.  Konig,  Poppert,  Mtiller,  CoUison,  and  Bloodgood  report 
good  results  following  resection  of  various  joints  which  were  ankylosed  in  a 
deformed  position.  While  the  disease  is  not  cured  or  even  arrested  in  this 
way,  yet  such  good  functional  results  follow,  and  the  condition  is  temporarily 
improved  to  such  an  extent,  that  no  hesitancy  should  be  felt  about  perform- 
ing resection.  In  the  treatment  of  arthritis  deformans  in  children  and 
young  adults,  good  results  follow  the  use  of  appropriate  apparatus  to  prevent 
further  and  to  correct  existing  deformities.  Local  measures — as  ointments  of 
ichthyol,  iodin,  and  mercury,  hot  air,  massage,  and  electricity — exert  a  favorable 
influence  upon  the  course  of  the  disease.  Apparatus  limiting  motion  within 
the  painless  area  should  be  used.  When  ankylosis  with  deformity  has  taken 
plaCe,  it  may  be  forcibly  overcome,  if  fibrous,  under  anesthesia,  by  means  of 
forcibly  breaking  up  the  adhesions  and  performing  necessary  tenotomies; 
or  if  bony,  by  means  of  osteotomy  or  resection. 


CHAPTER  XXVII. 
TALIPES,  OR  CLUB-FOOT. 

The  generic  term  talipes,  or  club-foot,  as  suggested  by  Little,  signifies  an 
abnormal  position  of  the  foot,  whether  in  antero-posterior  or  transverse  plane, 
in  its  anatomic  relations  to  the  leg,  or  of  the  foot  to  itself. 

This  abnormal  position  may  consist  of  a  flexion,  extension,  inversion,  or 
aversion,  or  combinations  of  these,  but  is  popularly  applied  to  that  deformity 
in  which  the  foot  is  twisted  inward  so  that  the  weight  of  the  body  is  borne  upon 
the  outer  side  or  dorsum  of  the  foot. 

Synonyms. — English,  Reel-foot;  Stump-foot.  Latin,  Pes  Contortus. 
Greek,  Kyllosis.  French,  Pied-bot.  German,  Klumpfuss.  Italian,  Piede 
torto;   Stortodel  piede.     Spanish,  Pie  Truncado. 

Anatomy  of  the  Foot. 

It  may  be  instructive  here  to  review  briefly  the  anatomic  construction  and 
mechanism  of  the  natural  foot.  The  foot  includes  all  that  portion  of  the  inferior 
extremity  below  the  tibiotarsal  articulation,  consisting  of  the  tarsus,  metatarsus, 
and  phalanges,  and  in  the  adult  has  the  form  of  two  arches,  an  antero-posterior 
and  a  transverse,  each  with  its  convexity  or  dorsal  surface  above,  and  its  con- 
cavity or  plantar  surface  below. 

The  antero-posterior  arch,  the  most  important,  is  supported  upon  two 
piers  or  pillars,  and  has  its  summit  at  the  astragalus  and  ankle-joint.  This  has 
been  still  further  divided  into  two  arches,  an  outer  and  an  inner,  by  an  imaginary 
line  drawn  posteriorly  between  the  third  and  fourth  metatarsal  bones.  The 
inner  portion  of  the  antero-posterior  arch  is  much  more  curved  than  the  outer, 
and  forms  the  instep. 

The  posterior  pier,  formed  by  the  posterior  parts  of  the  astragalus  and 
OS  calcis,  is  shorter,  more  curved,  has  but  one  joint,  and  is  more  solid,  receiving 
the  greater  part  of  the  weight  of  the  body.  The  anterior  pier,  composed  of  the 
scaphoid,  three  cuneiform,  and  three  inner  metatarsal  bones,  is  longer,  less 
curved,  has  many  joints,  and  is  more  elastic,  serving  to  diminish  the  force  of 
shocks  transmitted  to  the  arch.     The  head  of  the  astragalus,  fitting  into  the 

759 


760  ORTHOPEDIC  SURGERY. 

concave  surface  of  the  scaphoid,  and  its  postero-inferior  surface,  articulating 
with  the  anterior  surface  of  the  os  calcis,  may  be  regarded  as  the  keystone, 
though  differing  in  many  respects  from  such  bodies  as  usually  employed.  The 
weak  part  of  the  arch  is  strengthened  by  the  interosseous  ligaments,  particularly 
the  inferior  calcaneo-scaphoid,  which  supports  it  from  below,  while  beneath, 
the  inner  portion  of  the  plantar  fascia  adds  additional  strength.  The  outer 
portion  of  the  antero-posterior  arch  consists  of  the  outer  portion  of  the  os  calcis, 
cuboid,  and  the  two  outer  metatarsal  bones.  It  is  strengthened  by  the  calcaneo- 
cuboid ligaments  and  the  outer  portion  of  the  plantar  fascia.  Both  arches 
are  still  further  maintained  by  the  tibialis  posticus  and  peronei  muscles,  par- 
ticularly the  peroneus  longus.  The  transverse  arch,  formed  on  the  inner  and 
outer  sides  by  the  bones  entering  into  the  inner  and  outer  antero-posterior 
arches  respectively,  varies  in  degree  of  curvature  in  different  portions  of  the  foot, 
being  most  marked  across  the  cuneiform  bones.  It  affords  protection  to  the 
soft  parts  of  the  sole,  and  adds  to  the  elasticity. 

To  appreciate  more  thoroughly  the  deformities  under  consideration,  the 
foot  is  best  divided  anatomically  into  an  anterior  portion,  the  "pes"  or  foot 
proper,  and  the  posterior  portion,  the  "talus"  or  ankle.  These  articulate  at 
the  medio-tarsal  or  Chopart's  joint,  formed  between  the  os  calcis  and  astragalus 
behind,  and  the  cuboid  and  scaphoid  in  front,  a  joint  which  admits  in  a  limited 
degree  of  every  variety  of  movement — flexion,  extension,  abduction,  adduction, 
and  rotation. 

The  amount  of  lateral  deviation  of  which  the  normal  foot  is  capable  is  well 
shown  by  obtaining  outline  tracings  of  the  foot,  using  one  of  the  methods  pre- 
viously described.  Upon  this  outline  the  mid-tarsal  joint  is  marked  by  a  straight 
line  drawn  from  a  point  just  posterior  to  the  tuberosity  of  the  scaphoid  on  the 
inner  side  to  a  point  midway  between  the  base  of  the  fifth  metatarsal  and  the 
tip  of  the  external  malleolus  on  the  outer  side.  To  obtain  a  correct  basis  of 
measurement,  the  mid-tarsal  joint  is  taken  as  a  base-line,  erecting  upon  it  a 
perpendicular  corresponding  to  the  long  axis  of  the  os  calcis.  Another  line  is 
drawn  from  the  intersection  of  these  two  lines  through  the  ball  of  the  great  toe. 
The  angle  formed  by  this  last  line  and  the  perpendicular  line  is  the  angle  of 
deflection  of  the  foot.  In  this  manner  the  angle  of  deflection  was  found  to  range 
between  26  and  37  degrees  {average,  20  males,  34.8  degrees;  12  females,  31.5 
degrees),  typical  examples  of  which  are  seen  in  the  accompanying  figures  (Figs. 
578  to  581). 

The    tibio-tarsal    or   ankle-joint   admits    of   flexion    and    extension,  and, 


TALIPES,  OR  CLUB-FOOT. 


761 


according  to  Gray,  in  extreme  extension  of  a  slight  amount  of  adduction  also. 
This  is  in  consequence  of  the  articular  surface  of  the  astragalus  being  wider  in 
front  than  behind,  so  that  in  complete  extension  the  narrowest  part  of  the 
astragalus  is  lodged  in  the  widest  part  of  the  tibio-fibular  arch,  admitting  of 
lateral  motion.     In  the  flexed  position,  however,  no  lateral  motion  is  possible. 

The  normal  amount  of  flexion  and  extension  of  the  foot  is  as  follows:  Ex- 
tension in  the  adult  is  limited  at  about  135  degrees,  or  45  degrees  more  than  a 
right  angle,  using  the  long  axis  of  the  tibia  as  the  plane  of  measurement.  Flexion 
stops  at  about  70  degrees,  or  20  degrees  less  than  a  right  angle.  The  position 
of  the  foot  in  standing  upon  an  even  sur- 
face, with  the  knee  in  full  extension,  is 
about  90  degrees.  The  amount  of  flexion 
and  extension  varies  in  different  individ- 
uals, but  these  figures,  based  upon  actual 
experiment  and  measurement,  represent 
the  average  of  normal  movement  in  the 
living  adult  subject. 

In  the  normal  condition  of  the  foot 
these  movements  are  accomplished,  and  a 
correct  anatomic  relation  of  the  parts  is 
preserved,  by  the  muscles  of  the  leg,  which 
may  be  conveniently  divided  into  four 
groups,  moving  the  foot  in  four  directions. 

Thus,  the  anterior  group  of  muscles — 
the  tibialis  anticus,  extensor  longus  digi- 
torum,  and  peroneus  tertius — act  upon  the 
foot  as  flexors;  the  superficial  set  of  the 
posterior  group— the  gastrocnemius,  soleus, 

and  plantaris,  assisted  by  the  peroneus  longus — act  as  extensors ;  the  deep  set  of 
the  posterior  group — the  flexor  longus  digitorum  and  tibialis  posticus,  assisted 
by  the  tibialis  anticus — act  as  adductors;  and  the  external  or  fibular  group,  the 
three  peronei  (longus,  brevis,  and  tertius)  act  as  abductors. 

The  weight  of  the  body  is  received  by  the  astragalus,  the  highest  part  of 
the  arch,  and  transmitted  to  the  ground  through  the  two  piers  of  the  antero- 
posterior arches.  The  foot  in  extension  rests  normally  upon  the  heel,  the  tips  of 
the  metatarsal  bones,  and  the  outer  side  of  the  sole,  the  weight  of  the  body  in 
standing,  walking,  running,  or  dancing  being  transmitted  through  the  heel. 


Fig.   577. — Diagram  Illustrating   Range 
OF  Motion  in  Normal  Foot. 


762 


ORTHOPEDIC  SURGERY. 


the  ball  of  the  great  toe,  and  that  of  the  little  toe — the  natural  tripod  of  the  foot 
— in  the  order  named. 

Thus  the  direction  of  the  weight  upon  the  arches  is  constantly  changing, 
and  it  is  only  through  the  action  of  these  muscles  that  the  normal  arches  are 


Fig.  578. 


Fig.  579. 


Figs.   578,579. — Angle  of  Deflection,  Normal 
Male  Feet  (Roberts). 


Fig.  580. 


Fig.  581. 


Figs.  580,581. — Angle  of  Deflection,  Nor- 
mal Female  Feet  (Roberts). 


Fig.  582. 


Fig.  583. 


Figs.-  582,  583. — Angle  of  Internal  Deflec- 
tion IN  Valgus  (Roberts). 


Fig.  5S4. 


Fig.  585. 


Figs.    584,  585. — Angle  of  Adduction    of  Varus 
(Roberts). 


preserved.  Thus  in  flexion  the  antero-posterior  arch  is  increased  by  the  action 
of  the  tibialis  anticus,  peroneus  tertius,  and  extensor  longus  digitorum;  and 
in  extension,  by  the  action  of  the  gastrocnemius,  soleus,  plantaris,  and  per- 
oneus longus,  both  the  cur\'es  are  diminished,  and  the  foot  flattened.     Then, 


TALIPES,  OR  CLUB-FOOT.  763 

also,  when  the  foot  is  markedly  flexed  the  foot  is  adducted,  and  when  markedly 
extended  it  is  abducted,  in  which  positions  the  arches  are  respectively  increased 
and  diminished.  It  is  important  to  remember  that  the  attachment  of  the  various 
muscles  to  the  foot  has  an  important  influence  in  maintaining  the  plantar  arches, 
and  that  the  integrity  of  these  arches  depends  upon  the  evenly  balanced  action 
of  the  antagonistic  muscles.  Thus,  the  tibial  and  peronei  muscles  are  antagon- 
istic, yet  their  combined  action  is  an  important  factor  in  the  maintenance  of 
both  the  transverse  and  anteroposterior  arches. 

If  the  equilibrium  be  disturbed,  the  action  of  a  single  group  wUl  produce 
one  of  the  simple  varieties  of  the  deformity,  or,  two  groups  acting  together,  one 
of  the  compound  varieties.     This  is  well  exhibited  in  the  foUowing  table: 


I  Gastrocnemius. 

Extension   (equinus) , i  ^, 

^  I  Plantaris. 

[  Peroneus  longus. 

r  Tibialis  anticus. 

Flexion  (calcaneus), \  Peroneus  tertius. 

I  Extensor  longus  digitorum. 

r  Tibialis  anticus. 

Adduction  (varus), -|  Tibialis  posticus. 

I  Flexor  longus  digitorum. 

r  Peroneus  longus. 

Abduction   (valgus), -,'  Peroneus  brevis. 

I  Peroneus  tertius. 


Varieties. 

Systematic  writers  usuaUy  classify  varieties  of  club-foot  under  congenital 
and  acquired,  but  they  are  most  conveniently  divided  into  two  classes,  the  simple 
and  compound.  Of  the  former  there  are  four  varieties,  two  on  a  lateral  plane, 
talipes  varus  and  talipes  valgus,  and  two  on  the  antero-posterior  plane,  talipes 
equinus  and  talipes  calcaneus. 

1.  In  talipes  varus  the  inner  side  of  the  foot  is  raised,  the  sole  turned  inward, 
and  the  anterior  portion  adducted. 

2.  In  talipes  valgus,  its  opposite,  the  outer  side  of  the  foot  is  elevated, 
and  the  sole  everted. 

3.  In  talipes  equinus  the  heel  is  elevated,  the  foot  extended,  and  the  patient 
walks  on  the  balls  of  the  toes. 


764  ORTHOPEDIC  SURGERY. 

4.  In  talipes  calcaneus  the  toes  are  raised,  the  foot  flexed,  and  the  patient 
walks  on  the  heel. 

To  these  simple  forms  some  authors  have  added  others,  and  three  addi- 
tional simple  varieties  are  now  recognized,  talipes  cavus,  talipes  planus,  and  non- 
deforming  club-foot.  In  talipes  cavus  the  arch  of  the  foot  is  increased;  in 
talipes  planus,  its  opposite,  the  arch  is  diminished  and  the  sole  rests  on  the 
ground;  and  in  the  non-deforming  club-foot  of  Shaffer — an  incomplete  equinus 
— there  is  little  or  no  deformity,  but  normal  flexion  is  limited  and  mobility 
modified.  Combinations  of  these  simple  forms  will  present  the  compound 
varieties,  as  equino-varus,  equino-valgus,  calcaneo-varus,  calcaneo-valgus,  etc. 
These  may  be  conveniently  arranged  as  follows: 


Simple, 


Lateral \  ^'^"^"S" 

valgus. 


Compound, 


Other  forms, 


i  Antero-posterior, \  equmus. 

[  (  calcaneus. 

I  Equino-, f  ^a™^- 

I  [  valgus. 

■  Calcaneo- J  ^^'^^• 


[  {  valgus 

I  Cavus. 
j  Planus. 

I  Non-Deforming  (Shaffer). 
Neuromimesis. 


Relative  Frequency. — In  estimating  the  relative  frequency  of  the  difl'erent 
varieties  some  difficulty  is  experienced,  owing  chiefly  to  the  different  nomen- 
clature employed  by  those  collecting  statistics.  Allowing  for  these  discrepan- 
cies, there  are  numerous  statistics  from  which  we  may  estimate  the  relative 
frequency  of  these  affections. 

Tamplin  tabulated  6754  cases  of  club-foot,  of  which  1780  were  congenital 
and  4974  acquired,  by  which  it  is  shown  that  the  greater  number  were  of  the 
acquired  variety,  the  proportion  being  about  as  3  to  i . 

The  relative  frequency  of  the  congenital  and  acquired  forms  is  also  well 
shown  in  the  746  cases  recorded  by  Roberts  from  records  of  the  New  York 
Orthopedic  Hospital  and  the  Orthopedic  Dispensary  of  the  University  of  Penn- 
sylvania, of  which  213  were  congenital  and  533  acquired.     They  were  as  follows: 


TALIPES,  OR  CLUB-FOOT.  7()5 

Congenital.  Acquired. 

Equinus, S  87 

Calcaneus, 3  31 

Varus, 73  66 

Valgus, 29  236 

Equino-varus, 95  68 

Equino-valgus, 3  9 

Calcaneo-varus,  o  2 

Calcaneo-valgus, 5  34 

Totals, 213  533 


Duval  has  recorded  1000  cases  of  club-foot,  of  which  574  were  congenital, 
and  of  these  364  were  in  males,  210  in  females.  Though  including  a  greater 
number  of  congenital  cases,  these  figures  are  interesting  as  exhibiting  the  relative 
frequency  of  the  varieties  and  greater  liability  of  the  male  sex. 

Cases.         Boys.         Girls. 

Equinus  and  equino-varus, 417 

Varus, 532 

Valgus, 22 

Calcaneus, 9 

Extreme  calcaneus,   20 

Totals, 1000  550  450 

The  primitive  congenital  equinus  is  exceedingly  rare. 

Chaussier,  out  of  23,923  newly  born  infants,  found  132  affected  with  various 
deformities,  37  of  them  having  club-foot;  and  Lannelongue,  out  of  15,229  births 
at  the  Paris  Maternity  Hospital,  covering  a  period  of  ten  years,  from  1858  to 
1867,  collected  108  deformed  infants,  of  which  8  had  club-foot,  or  a  proportion 
of  I  case  in  1903  births. 

K.  Roser  found  among  100  deformed  fetuses  36  with  club-foot,  of  which 
8  were  double  talipes  varus,  11  double  calcaneus,  9  calcaneovarus,  and  9  with 
unilateral  club-foot. 

These  statistics  taken  together  are  sufficient  to  show  the  frequent  associa- 
tion of  club-foot  with  other  deformity;  its  greater  frequency  on  the  right  side, 
and  in  the  male;  the  relative  greater  frequency  of  double  club-foot;  the  pre- 
ponderance of  equino-varus  as  a  congenital  variety,  and  the  variety  of  primitive 
forms. 


215 

202 

302 

230 

14 

8 

6 

3 

13 

7 

766  ORTHOPEDIC  SURGERY. 

Etiology. 

The  etiology  of  talipes  may  be  divided  into  two  great  classes — the  con- 
genital and  the  acquired. 

The  Etiology  of  Congenital  Club-foot.— The  study  of  the  cause  of  con- 
genital club-foot  involves  much  that  is  mysterious  and  unexplained,  from  the 
fact  that  there  is  no  direct  scientific  means  of  investigation  except  such  data 
as  embryologic  research,  comparative  physiology,  and  post-natal  life  and  dis- 
ease furnish.  Hence  there  is  much  that  is  purely  speculative,  and  numerous 
views  have  been  advanced  and  defended  from  time  to  time.  These  may  be 
considered  under  the  following  heads: 

1.  Theory  of  heredity. 

2.  Theory  of  mechanical  pressure,   or  intrauterine  pressure  theory. 

3.  Theory  of  pre-natal  disease,  or  musculo-nervous  theory. 

4.  Theory  of  arrest  of  development,  or  osseous  theory. 

5.  Theory  of  retarded  rotation  or  non-rotation  of  extremities. 

Maternal  impressions.  In  exceptional  instances  the  striking  resem- 
blance of  deformity  to  some  object  seen  by  the  mother  during  her  pregnancy 
has  led  the  laity  to  consider  maternal  impressions  as  in  some  occult  manner 
producing  these  deformities.  Upon  closer  investigation,  however,  the  fright  or 
observation  is  found  to  correspond  to  a  period  of  gestation  when  it  could  have 
had  no  influence  upon  the  production  of  the  deformity.  They  can  be  readily 
accounted  for  under  existing  physical  causes,  or  are  simply  striking  coincidences. 
Dabney,  in  ninety  collected  cases  of  maternal  impressions  apparently  producing 
deformity,  did  not  find  a  single  case;  and,  according  to  a  recent  authority, 
there  is  no  recorded  case  of  the  development  of  club-foot  produced  by  mater- 
nal impression. 

1.  Heredity,  exerting  its  influence  through  one  or  both  parents,  is  undoubt- 
edly a  factor  in  the  etiology  of  these  cases.  Particularly  is  this  true  of  consan- 
guineous marriages,  which  are  so  productive  of  deformities  generally. 

Devay  and  Boudin  report  i  case  in  164  births  from  marriages  of  kin,  against 
I  case  in  1903  of  other  marriages.  Reeves  and  Brodhurst  have  known  several 
striking  illustrations,  in  which  some  form  of  club-foot,  and  generally  equino- 
varus,  ran  through  various  members  of  the  same  famUy.  Adams  gives  a  very 
interesting  history  of  a  club-footed  family.  The  writer  has  recently  operated 
upon  a  child  whose  father,  in  his  infancy,  was  operated  upon  in  Russia,  by 
Pirogoff,  for  a  similar  deformity. 

2.  The  theory  of  mechanical  or  intrauterine  pressure  on  the  fetus, 


TALIPES,  OR  CLUB-FOOT.  767 

through  deficient  liquor  amnii  compression  of  the  uterus  by  another  part  of  the 
fetus,  or  the  abnormal  position  and  action  of  the  umbilical  cord,  or  of  amniotic 
bands,  is  as  old  as  Hippocrates.  Ambroise  Pare  supported  it,  and  ascribed 
club-foot  to  the  circumstance  that  "the  mother,  during  her  pregnancy,  had  been 
sitting  too  much  with  her  legs  crossed."  Cruveilhier  supported  the  pressure 
view,  but  added  traumatism  as  an  elementary  factor.  Malgaigne,  Volkmann, 
Kocher,  Parker,  Vogt,  and  others  supported  this  mechanical  theory  of 
pressure  and  malposition  in  utero.  The  fact  is  well  established  that  club- 
foot may  occur  through  the  interlocking  of  the  feet  of  the  fetus,  and  their 
compression  or  retention  in  this  position.  Against  this  theory  many  objections 
have  been  raised.  If  uterine  pressure  were  an  influential  factor,  other  organs 
would  exhibit  pressure  evidences,  and  club-hands,  legs,  and  thighs  would  be 
common,  instead  of  the  rarest  of  deformities.  Then,  again,  no  appreciable 
difference  is  observed  in  the  quantity  of  liquor  amnii  over  previous  births  of 
healthy  children,  and  Duval  has  asserted  the  reverse.  Furthermore,  the  defor- 
mity is  observed  before  the  fourth  or  fifth  month  of  intrauterine  life,  when 
the  amniotic  fluid  is  abundant  and  no  pressure  is  possible.  Cases  of  twin  births 
have  been  recorded,  notably  one  of  Roberts  and  Ketch,  of  "double  equino-varus 
in  a  twin,  the  other  child  showing  no  deformity  whatsoever." 

3.  The  musculo-nervous  theory,  the  alteration  of  the  muscles,  with  or 
without  a  central  nervous  lesion,  has  been  supported  by  a  galaxy  of  celebrities. 
Morgagni,  Benjamin  Bell,  Duverney,  Rudolphe,  Beclard,  Jules  Guerin,  and 
Delpech,  have  all  given  it  the  weight  of  their  indorsement,  the  last-named  being 
among  the  first  to  consider  the  influence  of  the  malformation  of  the  tarsal  bones. 

The  majority  of  these  considered  a  contraction  of  certain  muscles  the  cause 
of  the  deformity;  Rudolphe  ascribed  this  contraction  to  intrauterine  convulsions. 
Chance  and  Little  also  inclining  to  this  view,  while  Beclard  and  Barwell  attri- 
buted it  to  weakness  or  paralysis  of  other  muscles.  Guerin  believed  this  con- 
vulsive muscular  retraction  to  be  secondary  and  consecutive  to  a  central  nervous 
lesion,  in  some  cases  demonstrable,  in  others  not.  The  microscope  has  not  re- 
vealed changes  in  the  fetal  brain  or  cord,  nor  do  the  electric  reactions  correspond 
to  those  met  in  acquired  cases.  Chaussier,  in  37  cases  of  club-foot,  and  Duval, 
in  574  cases  of  the  same,  found  no  other  deformity  associated.  The  frequent 
association  of  club-foot  with  spina  bifida,  hydrocephalus,  and  anencephalus,  is 
confirmatory  of  this  association;  contrariwise,  many  fetuses  are  met  having  exten- 
sive nervous  lesions  but  devoid  of  club-foot.  Thus,  Lannelongue  found  only 
four  fetuses  with  club-foot  among  the  32  cases  of  spina  bifida  and  encephalocele. 


76S  ORTHOPEDIC  SURGERY. 

4.  The  osseous  theory,  or  theory  of  arrest  of  development,  the  permanence 
of  the  feet  in  the  physiologic  position  of  the  sixth  or  seventh  fetal  week,  with  the 
sole  turned  inward,  has  been  maintained  by  Geoffroy  Saint-HHaire,  INIeckel, 
Breschet,  Adams,  Hueter,  Eschricht,  and  others.  This  anatomic  fact  has  been 
denied  by  Cruveilhier,  but  has  received  the  support  of  Martin  and  others.  While 
the  coexistence  of  club-foot  with  such  deformities  as  spina  bifida,  hare-lip,  and 
cleft  palate  would  seem  to  be  confirmatory  of  this  theory  of  arrest  of  development, 
yet,  in  such  cases,  the  feet  themselves  exhibit  no  arrest  of  development,  but 
only  such  changes  as  occur  in  cases  unassociated  with  other  deformity. 

A  modification  of  this  theory  of  arrest  of  development,  ascribing  the  cause 
to  primary  changes  in  the  tarsal  bones,  principally  the  astragalus  and  os  calcis, 
has  been  supported  by  Scarpa,  Broca,  Bouvier,  Brocher,  Robin,  Lannelongue, 
Thorens,   and  others. 

These  osseous  changes  are  by  no  means  constant,  and  much  difference 
of  opinion  exists  as  to  whether  they  are  primary  and  causative,,  or  secondary, 
as  the  result  of  pressure. 

5.  The  theory  of  non-rotation  or  retarded  rotation  was  proposed  by 
Berg,  of  New  York  ("Archives  of  Medicine,"  New  York,  December  i,  1882), 
announced  independendy  by  Parker  and  Shattuck  ("British  Medical  Journal," 
1886,  vol.  ii,  p.  10),  confirmed  by  Scudder  ("Boylston  Prize  Essay,"  "Boston 
Medical  and  Surgical  Journal,"  October  27,  1887),  and  favored  by  Roberts  and 
Ketch,  Bradford  and  Lovett,  the  writer,  and  others. 

Berg,  from  a  series  of  embryologic  investigations,  studied  the  changes  in 
the  position  of  the  lower  extremities  at  different  periods  of  fetal  life.  From 
the  flexed  and  crossed  position  of  the  lower  extremities,  all  the  intrauterine 
pressure  was  brought  to  bear  direcdy  upon  the  outer  side  of  the  thigh  and  leg 
corresponding  to  the  fibular  border  of  the  leg  and  upon  the  dorsum  of  the  foot, 
resulting  in  the  foot  being  placed  in  a  position  of  equino-varus,  which  he  believes 
to  be  a  stage  in  the  normal  development  of  every  healthy  fetus.  To  provide 
against  the  permanence  of  this.  Nature  provides  an  inward  rotation  of  the 
extremity,  carrying  the  leg  away  from  its  position  against  the  abdomen  of  the 
fetus,  bringing  the  soles  of  the  feet  against  the  uterine  walls  in  extreme  flexion, 
and  the  force  of  the  intrauterine  pressure  directly  upon  them. 

Bessel-Hagen  states  that  the  torsion  of  the  foot  varies  in  individuals,  and 
also  that  at  no  time  does  the  foot  normally  assume  the  clubbed  position.  He 
says  that  in  an  embryo  30  mm.  in  length  the  foot  is  normally  in  extreme  plantar 
flexion,  and  that  in  an  embryo  90  to  100  mm.  long  the  foot  is  at  right  angles  to  the 


TALIPES,  OR  CLUB-FOOT.  769 

leg,  and  from  this  time  may  be  adducted,  abducted,  or  dorsi-flexed.  Supina- 
tion near  term  is  the  more  common  attitude  and  is  usually  combined  with 
dorsi-flexion.  Furthermore,  the  leg,  if  the  rotation  were  the  cause,  would  in 
talipes  varus  be  rotated  outward,  whereas,  in  fact,  the  rotation  is  usually 
inward.  However,  although  Eschricht's  and  Berg's  theory  be  refuted,  it  would 
seem  that,  according  to  Bessel-Hagen  and  Scudder,  there  is  undoubtedly  a 
change  in  attitude  of  the  legs  and  feet  during  gestation,  which  more  or  less 
closely  follows  a  fixed  rule.  Therefore  if  from  any  mechanical  cause  they  become 
"caught"  in  any  of  these  positions,  a  deformity  will  result. 

In  conclusion,  while  the  subject  of  etiology  of  club-foot  is  still  unsettied, 
these  investigations  seem  to  point  to  a  failure  of  rotation  or  to  non-rotation  as  a 
demonstrable  theory,  and  one  which  is  eminently  scientific  and  feasible;  but  it 
would  seem  most  reasonable  that  mechanical  fixation  of  an  abnormal  position 
of  the  foot  is  responsible  for  the  majority  of  the  congenital  forms. 

Etiology  of  Acquired  Forms. — As  before  pointed  out  in  speaking  of  rela- 
tive frequency,  by  far  the  greater  number  of  cases  are  of  the  acquired  variety, 
and  the  majority  of  these  are  paralytic. 

Those  which  are  not  paralytic  are  usually  mechanical  in  origin.  Thus  an 
equinus  may  result  from  the  pressure  of  the  bedclothes  in  long-continued 
decubitus,  as  in  continued  fevers,  as  in  a  case  recorded  by  Volkmann  following 
typhoid.  Osteitis  of  the  tarsus,  anlde-joint,  or  the  lower  end  of  the  tibia  not 
involving  the  ankle-joint,  as  in  a  case  of  equinus  in  a  young  woman  seen  by  the 
author,  are  frequent  causes  of  acquired  talipes.  In  addition  to  equinus,  varus 
and  valgus  positions  may  also  be  produced. 

Occupations  necessitating  long-continued  standing,  as  cooks,  bakers, 
■printers,  and  other  trades,  frequently  give  rise  to  inflammatory  forms  of  the 
affection,  especially  valgus. 

A  somewhat  peculiar  form  of  valgus — valgus  adolescentium — is  met  about 
puberty,  depending  upon  rapid  growth  and  increase  of  weight  without 
a  corresponding  increase  of  strength  in  the  plantar  arch. 

Rachitic  changes,  particularly  knock-knee,  occurring  about  the  seventh 
year,  are  another  cause  of  acquired  club-foot  of  the  valgus  variety. 

Injuries,  particularly  Pott's  fracture,  luxations  of  the  ankle-joint,  burns, 
and  extensive  cicatrices  about  the  foot  or  ankle-joint,  are  causes  of  the  acquired 
varieties. 

That  deformities  of  the  feet  may  depend  upon  the  neurotic  diathesis,  as 
pointed  out  by  Shaffer,  is  now  admitted,  but  that  they  may  result  from  reflex 


770  ORTHOPEDIC  SURGERY. 

paralysis,  as  a  muscular  spasm  from  functional  disturbance  of  the  nervous 
system,  has  been  doubted  by  many  authorities.  Of  the  former — the  neuro- 
mimeses  of  club-foot — numerous  interesting  cases  have  been  recorded,  notably 
those  by  Weir  Mitchell,  Little,  Paget,  Skey,  and  others. 

A  few  cases  of  acquired  club-foot  have  been  recorded  from  pseudo-hyper- 
trophic  paralysis,  post-hemiplegic  contractions,  a  large  number  resulting  from 
tetanoid  paraplegia,  but  by  far  the  greater  number  occur  from  infantile  paralysis 
or  poliomyelitis  anterior.  These  latter  will  be  considered  in  detail  in  their 
appropriate  places,  but  it  may  here  be  stated  that  the  talipes  resulting  from  the 
tetanoid  paraplegia  is  of  the  equinus  variety,  and  that  resulting  from  infantile 
paralysis  is  usually  of  the  calcaneus  and  valgus  varieties. 

In  these  paralytic  forms,  as  pointed  out  by  Volkmann,  the  club-foot  does  not 
result  from  tonic  contraction,  but  faulty  positions  of  the  feet  assumed  to  better 
support  the  body  become  permanent  deformities  through  growth  of  the  limb. 

There  is  also  a  temporary  form  of  equinus,  spastic  in  nature,  accompanying 
the  paraplegia  of  Pott's  disease. 

Symptoms. 

In  addition  to  the  unsightly  appearance,  club-foot  necessitates  a  peculiar 
and  characteristic  method  of  progression,  depending  upon  the  variety  of  the 
affection.  Thus,  in  double  equino-varus  the  feet  are  lifted  over  one  another, 
in  valgus  the  foot  is  swung  outward  and  forward,  flail-like,  as  each  step  is  taken, 
in  equinus  the  locomotion  partakes  of  a  springing  gait,  etc.  In  severe  cases, 
bursse,  callosities,  and  severe  inflammation  and  ulceration  result  from  pressure 
upon  unprotected  parts,  which  diminishes  the  activity  and  capabilities  of  the 
patient,  necessitating  sitting  occupations,  and  at  times  becoming  so  aggravated 
as  to  demand  amputation.  Those  afflicted,  likewise,  are  liable  to  become  a 
burden  to  the  State  through  their  inability  to  earn  a  living. 

Aside  from  the  physical  discomfort  and  suffering,  club-foot  when  severe  is 
a  source  of  great  psychic  suffering.  Thus  Talleyrand  is  said  to  have  entered 
the  Church,  and  Lord  Byron  is  said  to  have  suffered  greatly,  on  account  of 
deformities  of  this  kind. 

Diagnosis. 

Little  difficulty  is  experienced  m  recognizing  club-foot  or  in  differentiating 
its  individual  varieties.  In  estimating  the  degree  of  the  deformity,  due  attention 
must  be  given  to  the  range  of  mobility  of  the  foot  as  given  under  its  normal 


TALIPES,  OR  CLUB-FOOT.  771 

anatomy;  and  in  establishing  the  severity  of  the  apparent  distortion,  due  atten- 
tion should  be  paid  to  the  age  of  the  individual  or  length  of  time  the  affection 
has  existed,  the  extent  to  which  it  can  be  corrected  by  manual  means,  and  the 
existence  of  spasm  or  paralysis.  Authors  have  attempted  to  divide  the  con- 
genital equino-varus  into  three  stages,  according  to  the  degree  of  severity,  but 
these  divisions  being  more  arbitrary  than  real,  have  but  little  practical  value, 
and  a  division  into  (i)  infantile,  (2)  neglected,  and  (3)  relapsed,  would  probably 
be  of  more  service.  The  acquired  forms,  however,  particularly  pes  valgus 
acquisitus,  admit  of  such  a  division — the  division  into  three  forms,  (i)  slight, 
(2)  medium,  and  (3)  severe,  bemg  the  one  preferred. 

Prognosis. 

These  deformities  do  not  correct  themselves,  but  if  uncorrected  grow 
progressively  worse,  but  two  cases  of  spontaneous  recovery  from  congenital 
club-foot  ever  having  been  recorded.  The  prognosis,  therefore,  wUl  depend 
entirely  upon  the  form  of  treatment  employed.  Under  the  older  mechanical 
methods  failure  in  severe  cases  was  frequently  the  result  even  after  prolonged 
treatment.  Under  present  methods  there  is  a  certainty  of  curing  club-foot 
never  before  obtained,  and  no  branch  of  surgery  meets  with  greater  success 
than  does  the  surgical  treatment  of  club-foot.  The  time  required  to  accomplish 
a  cure  varies  with  the  method  adopted,  from  a  few  weeks  to  two  or  three  months, 
and  this  will  depend  upon  the  merits  of  the  individual  case.  If  the  cases  have 
been  slightly  over-corrected, — and  this  should  be  the  rule, — relapses  will  be 
rare  occurrences.  To  avoid  this,  however,  retentive  or  walking  apparatus  will 
be  required,   particularly  in  the  younger  cases. 

In  severe  neglected  or  relapsed  cases  where  extensive  bone-cutting  operations 
are  necessary  extensive  sloughing  sometimes  occurs,  and  deaths  have  been 
recorded.  In  160  cases  collected  by  Lorenz  there  were  four  deaths.  In  400 
cases  collected  by  M'Kenzie,  of  Toronto,  there  was  no  death,  and  no  ampu- 
tation.* I  have  had  the  most  severe  shock  follow  double  excision  of  the 
astragalus,  but  have  had  no  death. 

The  author  has  met  with  congenital  cases  in  adults  who  refused  treatment 
because  they  considered  the  deformity  a  dispensation  of  Providence,  and  dared 
not  incur  divine  displeasure  by  permitting  its  cure.  Such  cases  must  remain 
deformed.     The  mental  effect  upon  the  individual  after  a  correction  is  often 


■  "Am.  Jour.  Orth.  Surg.,"  Jan.,  1905,  p.  2S8. 


772 


ORTHOPEDIC  SURGERY. 


marked,  and  frequently  patients  are  enabled  to  pursue  occupations  and  respon- 
sibilities from  which  they  were  previously  debarred.  According  to  Dieffenbach, 
of  all  the  women  treated  by  him,  only  one  was  married,  indicating  the  asceticism 
of  humanity  in  matrimonial  affairs,  and  the  impediment  these  deformities  con- 
stitute to  marriage;  and  the  writer  is  also  acquainted  with  one  instance  where  a 
female,  beautiful  in  every  other  respect,  contracted  a  matrimonial  alliance 
notwithstanding  the  presence  of  this  horrible  deformity. 

Treatment. 

The  successful  treatment  of  club-foot  varies  according  to  the  variety ,  age 
of  patient,  duration,  and  nature  of  the  deformity;  but  it  demands  in  most  cases 
a    combination    of    operative,    mechanical,    and    orthopedic    treatment.     The 

orthopedic  and  mechanical  means  include  man- 
ipulations, massage  and  electricity,  and  the  ap- 
plication of  splints.  The  operative  means 
include  tenotomy,  division  of  ligaments,  myot- 
omy, tarsotomy  and  tarsectomy,  brisement  force, 
multiple  tenotomy  and  open  incision,  and 
amputation.  All  these  measures  aim  to  over- 
correct  the  deformity  slightly,  and  to  retain  it 
in  this  position  until  the  tendency  to  return 
has  been  overcome. 

Manipulations,  preferably  by  the  hand, 
^'°"  ^^'^•(Tl^b'-Zt  (HoSr""''  °'    are  as  old  as  Hippocrates,  and  have  from  his 

time  till  the  present  been  successfully  employed 
in  the  correction  of  many  congenital  cases.  In  fact,  in  all  mUd  congenital 
cases  an  attempt  should  be  made  to  correct  the  deformity  by  manipulations 
before  resorting  to  more  severe  measures.  In  the  compound  varieties — for 
example,  equino-varus — the  correction  should  be  divided  into  two  stages :  first, 
the  eversion  of  the  anterior  portion  of  the  foot;  second,  the  flexion  of  the  foot 
upon  the  leg.  The  foot  must  be  firmly  grasped  with  one  hand  while  the  other 
gently  but  firmly  forces  the  foot  into  the  correct  position.  This  should  be  daily 
performed,  and  in  the  intervals  the  feet  should  be  retained  in  their  improved 
position.  These  manipulations  must  not  be  omitted  until  the  foot  is  forced  into 
an  over-corrected  position  or  the  manipulations  are  abandoned  for  some  method 
more  radical.  These  forcible  methods  may  also  be  employed  under  an  anes- 
thptic,  and  in  this  manner  it  is  often  astonishing  how  much  can  be  accomplished 
by  manual  measures  alone. 


TALIPES,  OR  CLUB-FOOT. 


773 


Massage  and  electricity  are  particularly  useful  in  the  paralytic  varieties, 
but  they  are  almost  as  important  in  congenital  cases  as  a  part  of  the  after- 
treatment;  indeed,  the  writer  is  inclined  to  look  upon  the  after-treatment  of 
tenotomy,  which  includes  these  two  measures,  as  almost  as  important  as  the 
operation  itself. 

The  value  of  these  measures  in  the  acquired  varieties  cannot  be  overesti- 
mated. Especially  is  this  true  of  infantile  paralysis,  in  which  massage  not  only 
keeps  up  the  nutrition  of  the  muscles  and  reduces  the  wasting,  but  assists  in 
relaxing  the  shortened  and  contracted  muscles  and  tendons.  It  should,  if 
possible,  be  given  by  a  person  skilled  in  its  use,  and  should  not  be  continued  too 
long  at  each  application.  Ten  minutes  is  sufi&cient  if  but  one  leg  be  paralyzed. 
Electricity  may  be  applied  in  one  week  in  infantile 
paralysis,  provided  no  fever  nor  hyperesthesia  of 
the  muscles  be  present,  but  for  one  month  only  the 
mildest  currents  may  be  employed.     In  deciding 


Fig.  5S7. — Correction  of  Club-foot   by  Bandage  (Schreiber). 


Fig.  5 88  . — Equino-v.arus   Brace 
Applied. 


between  the  faradic  and  galvanic  currents,  the  current  which  gives  the  greater 
amount  of  contraction  with  the  weakest  current,  and  the  least  amount  of 
pain,  should  be  the  one  selected.  The  treatment  must  be  used  daUy  for  a 
short  duration  only;  four  or  more  contractions  for  each  muscle  are  sufficient. 
One  pole  (the  anode)  is  best  applied  over  the  nerve-trunk,  and  the  other  (the 
cathode)  is  successively  applied  firmly  over  the  entire  surface  of  the  limb. 

The  splints  employed  in  the  treatment  of  club-foot  may  be  divided  into 
two  classes :  first,  apparatus  intended  to  correct  the  faulty  position ;  second,  appa- 
ratus employed  to  retain  the  foot  in  a  corrected  position.  These  can  best  be 
described  under  the  varieties  for  which  they  are  designed,  and  the  principles 
upon  which  they  act  need  only  here  be  mentioned. 


774 


ORTHOPEDIC  SURGERY. 


Of  all  the  corrective  apparatus  in  use  the  internal  lateral  traction  shoe  of 
Shaffer  is  remarkable  for  its  ingenuity.  It  consists  of  a  steel  trough  fitted  to 
the  inner  side  of  the  leg,  from  the  upper  part  of  the  tibia  to  the  internal  malleolus. 
From  opposite  the  latter  point  a  hinge,  obliquely  placed,  connects  this  upright 
with  the  sole-plate.  An  endless  screw  acts  upon  this  hinge  in  such  a  manner 
as  to  correct  the  deformity  of  the  anterior  portion  of  the  foot.  The  sole-plate 
is  divided  opposite  the  mediotarsal  joint,  and  by  means  of  a  simple  screw  and 
lever,  or  the  more  powerful  triple  screw  of  Roberts,  allows  of  extreme  and  power- 
ful abduction  of  the  anterior  portion  of  the  foot. 

The  apparatus  is  applied  to  the  foot 
in  its  deformed  position,  and  by  means 
of  keys  the  correction  is  gradually  ac- 
complished by  the  action  of  this  power- 


FiG.   589. — Double    Eqotno-vahus    before 
Use  of  Traction  Shoe. 


Fig.  590. — S.4ME,  AFTER  Use  of  Traction  Shoe. 


ful  screw  force.     In  a  somewhat  similar  but  stUl  more  powerful  manner  exter- 
nal lateral  traction  is  applied. 

The  use  of  elastic  traction  has  the  advantage  of  not  interfering  with  the 
free  use  of  the  joints  and  muscles,  as  well  as  simplicity  of  application,  to  recom- 
mend it.  It  consists  essentially  of  a  zinc  plate  fastened  to  the  front  of  the  leg 
by  plaster,  which  serves  as  a  fixed  point  of  attachment  for  the  elastic  traction, 
and  a  fan-shaped  piece  of  plaster  cut  into  a  number  of  strips  and  carrying 
a  wire  loop  to  serve  for  the  second  point  of  attachment.  An  elastic  tube,  with 
a  hook  at  one  end  and  a  chain  at  the  other,  furnishes  the  traction  force. 
Elastic  traction  is  most  valuable  in  paralytic  deformities  to  supplement  the 
action  of  the  weaker  muscles. 


TALIPES,  OR  CLUB-FOOT. 


775 


The  retentive  apparatus  are  employed  in  the  intervals  between  the  manipu- 
lations to  maintain  what  has  been  secured,  or  are  applied  after  tenotomy  and 
other  cutting  operations,  to  maintain  the  parts  during  the  healing  process. 
These  may  be  constructed  of  metal  (zinc,  tin,  lead,  steel),  rubber,  felt,  or  prepared 


Fig.  591. — Shapfer's  Lateral  Splint  eor  Club-  Fig.  592. — Shaffer's  Later,«,  Splint  Applied. 

FOOT. 


Fig.  593. — Sole-plate  Extended. 

A,  Lateral  hinge ;  B,  screw ;  C,  toe  plate ;  D,  key; 

E,  heel  plate ;  F,  sole  plate. 


Fig.  594. — Brace  .Adjusted  to  Corkected  Posi- 
tion. 
A,  Screw ;  E,  foot  plate. 


leather,  and  retained  by  an  ordinary  roller  or  plaster-of-Paris  bandage.  More 
elaborate  apparatus  are  sometimes  employed.  The  plaster-of-Paris  cast,  well 
applied,  furnishes  the  simplest,  neatest,  and  best  retentive  apparatus.  In 
small  children,  and  when  the  dressing  is  carried  high  up  the  thigh,  the  plaster- 


776 


ORTHOPEDIC  SURGERY. 


of-Paris  dressing  should  be  reinforced  with  a  silicate  of  soda  bandage  or  coated 
with  shellac  to  render  it  impervious  to  water.  The  dressing  should  be  removed 
and  reapplied  every  week  or  ten  days,  at  which  time  the  limb  should  be  washed 
with  soap  and  water,  and  vigorously  rubbed  with  alcohol  or  soap-liniment. 
The  operative  treatment  of  club-foot,  the  remarkable  success  of  which 
has  already  been  mentioned,  includes  tenotomy,  syndesmotomy,  myotomy, 
tarsectomy,  tarsotomy,  hrisement  force,  and  amputation. 

Tenotomy. — Surgeons  differ  much  as  to  the  proper  time  at  which  to  per- 
form tenotomy  in  club-foot,  some  operating  very  early,  within  the  first  month, — 
Stromeyer  operated  upon  one  within  twenty-four  hours  of  birth, — and  others 
delaying  until  the  child  shows  an  inclination  to  walk.  Since  in  all  instances 
it  is  proper  to  endeavor  first  to  correct  the  deformity  by  manual  and  mechanical 
means,  and,  failing  in  this,  to  resort  to  operative 
procedures,  a  later  period  appears  to  me  prefer- 
able. Much  will  depend  upon  the  individual 
case,  but  from  eight  to  twelve  months  would 
appear  to  be  a  good  time  to  operate  upon  infan- 
tile cases.  The  later  period  has  also  this  advan- 
tage, that  faUing  by  subcutaneous  tenotomy  to 
rectify  the  deformity  entirely,  resort  can  at  once 
be  made  to  other  surgical  procedures,  to  be  dis- 
cussed presently. 

The  individual  tendons  most  frequently  re- 
quiring  division  in  club-foot  are,   in  the  order 
named,  the  tendo  Achillis,  tibialis  anticus,  tibialis 
posticus,  plantar  fascia,  and  peronei.     The  technic  of  the  division  of  each  has 
been  described  under  the  general  head  of  treatment  in  Part  I. 

Syndesmotomy. — In  some  instances  the  contractures  of  the  ligaments,  as 
the  astragalo-scaphoid  and  calcaneo-cuboid  ligaments  in  talipes  equino-varus, 
offer  the  greatest  resistance  to  the  reduction  of  the  deformity,  and  the  division 
of  these  has,  therefore,  been  advised  by  many  surgeons.  The  division  of 
these  ligaments  may  be  performed  by  the  percutaneous  and  subcutaneous 
methods.  Phelps,  in  his  open  incision,  has  advised  the  incision  of  the  internal 
lateral  or  deltoid  ligament  and  all  its  branches  by  an  extensive  subcutaneous 
curvUinear  incision,  the  tenotome  being  introduced  through  the  open  incision. 
The  astragalo-scaphoid  and  calcaneo-cuboid  ligaments,  the  ones  most  frequently 
requiring  division,  can  both  be  divided  subcutaneously.     To  divide  the  astragalo- 


FiG.   595.- 


-Club-foot  Walking 
Shoe. 


TALIPES,  OR  CLUB-FOOT. 


777 


scaphoid  ligament  the  tenotome  held  vertically,  edge  forward,  is  entered  imme- 
diately in  front  of  the  anterior  border  of  the  internal  malleolus,  and  passed  be- 
tween the  skin  and  ligaments.  The  blade  is  turned  toward  the  surface  of  the 
ligament,  and  by  a  gently  sawing  motion  the  division  is  accomplished.  By 
directing  the  point  of  the  knife  to  the  plantar  aspect  of  the  foot  and  keeping 
close  to  the  bone,  the  calcaneo-scaphoid  ligament  may  also  be  easily  divided. 
To  divide  the  long  and  short  plantar  (calcaneo-cuboid)  ligaments,  the  tenotome 
must  be  entered  behind  the  head  of  the  fifth  metatarsal  bone,  as  nearly  as 
possible  over  the  calcaneo-cuboid  articulation  on  the  outer  border  of  the  sole  of 
the  foot.  The  blade  is  passed  close  to 
the  bone  in  the  direction  of  the  articula- 
tion, and  the  section  of  the  two  liga- 
ments may  be  accomplished  simulta- 
neously. 

Myotomy. — The    division    of    the 


^^^^^^^^^^Hm  *>  .I^^^^^^^^H 

^^^^^^^^Hk^  ^^^^^^^H 

^^^^^v '  ^'''  ^'^^^^^H 

1^^^^^^^^%                  vU^^^^^^H 

^^■'  ^  VH 

^^^^^^B                    ^^^^^H 

Fig.  596. — Double  Equino-varus   before  Multiple 
Tenotomies. 


597. — S.'^ME,     AFTER    MULTIPLE    TENOT- 
OMIES. 


muscles  for  club-foot  is  but  seldom  resorted  to  at  the  present  time.  In  Phelps' 
operation  the  abductor  poUicis  and  flexor  brevis  muscles  are  divided.  Except 
in  this  operation,  myotomy  is  rarely  performed,  and  tenotomy,  when  possible, 
is  always  preferable. 

Tarsectomy  and  Tarsotomy,— The  cutting  operations  upon  the  tarsal 
bones  for  the  relief  of  talipes — about  eighteen  separate  operations  in  all — are 
included  under  these  two  heads;  the  former,  tarsectomy,  consisting  of  the 
removal  of  a  wedge-shaped  piece  of  bone;  the  latter,  tarsotomy,  consisting 
of  the  division  of  the  bonv  structure  of  the  tarsus  with  an  osteotome. 


"S 


ORTHOPEDIC  SURGERY 


The  following  enumeration,  slightly  modified  from  Roberts'  and  Ketch's 
valuable  article,  includes  aU  to  the  present  time: 

1.  Linear  osteotomy  of  the  scaphoid  practised  on  the  plantar  surface. 
(Hahn.) 

2.  Linear  osteotomy  of  the  tibia  above  the  malleolus.     (Hahn.) 

3.  Enucleation  of  the  cuboid.     (SoUy.) 

4.  Enucleation  of  the  astragalus  alone.     (Lund,  Maron.) 


Fig.  598. — AsTKAGALEciOMY,  SHO'mxG  Cicatrix. 


5.  Same,  with  resection  of  tip  of  external  malleolus.     (Alason,   Reid.) 

6.  Excavation  of  the  spongy  portion  of  astragalus,  leaving  the  articular 
surfaces.     (Verebely). 

7.  Enucleation  of  astragalus  and  excision  of  a  wedge-shaped  piece  from 
anterior  part  of  os  calcis.     (Hahn.) 

8.  Enucleation  of  astragalus  and  cuboid.     (Albert,  Hahn.)     Enucleation 
of  astragalus  and  scaphoid.     (^Vest.) 

9.  Enucleation  of  astragalus,  cuboid,  and  scaphoid.     (^Vest.) 


TALIPES,  OR  CLUB-FOOT. 


779 


10.  Enucleation  of  scaphoid  and  cuboid.     (Bernet.) 

11.  Resection  of  head  of  astragalus.     (Liicke,  Albert.) 

12.  Excision  of  wedge  from  outer  half  of  neck  of  astragalus.[^_;_(Hueter.) 


Fig.  599. — Author's  Case,  before  Astragalectomy. 


Fig.  600. — Same,  after  Operation. 


13.  Excision  of  two  wedges  perpendicular  to  each  other,  with  bases  at 
Chopart's  articulation  and  the  astragalo-calcanean  joint.     (Rydygier.) 

14.  Resection  of  a  wedge  without  regard  to  any  individual  bones.     (O. 
Weber,  Davies-Colley,  R.  Davy.) 


7S0  ORTHOPEDIC  SURGERY. 

15.  Linear  osteotomy  of  the  lower  end  of  the  tibia  and  fibula.  (Trendelen- 
burg, Willy  Meyer.) 

16.  Linear  osteotomy  of  the  neck  of  the  astragalus.     (Bradford.) 

17.  Removal  of  section  of  lower  fifth  of  fibula.     (Barton  Hopkins.) 

18.  Excision  of  astragalus,  scaphoid,  cuboid,  and  anterior  part  of  the  os 
calcis.     (Verneuil.) 

Of  these  eighteen  operations  two  only,  which  are  most  employed,  will  be 
described,  the  others  being  either  unsatisfactory,  insufficient,  or  too  mutilatory. 
These  three  are:   enucleation  of  the  astragalus,  and  wedge-shaped  tarsectomy. 

Astragalectomy,  or  enucleation  of  the  astragalus,  in  inveterate  cases 
of  club-foot  is  best  performed  as  follows :  The  foot,  duly  prepared,  is  supported 
in  a  strongly  inverted  position  upon  a  triangular  block.  An  incision  extending 
from  just  above  the  tip  of  the  external  malleolus  is  carried  forward  and  a  little 
inward,  curving  toward  the  dorsum  of  the  foot.  This  crosses  a  space  between 
the  peronei  tendons,  in  which  no  important  structures  are  found,  and  being 
carried  directly  down  to  the  bone,  the  latter  may  be  readily  exposed  and  removed 
to  avoid  bruising  the  surrounding  bony  structures,  and  in  dressing  the  strictest 
aseptic  precautions  should  be  enforced. 

Tarsectomy,  or  resection  of  a  wedge-shaped  piece  from  the  outer  side,  is 
best  performed  after  the  methods  of  Davies-Colley  and  Davy. 

The  cleansed  foot  is  supported  on  a  triangular  block  and  a  T-shaped 
incision  made  upon  the  outer  side  of  the  foot.  The  straight  incision  is  carried 
along  the  outer  border  of  the  foot,  from  the  middle  of  the  os  calcis  to  the  middle 
of  the  fifth  metatarsal  bone.  The  vertical  incision  at  right  angles  to  the  center 
of  this  enlarges  the  field  of  operation.  The  flaps  are  reflected,  the  tendons 
and  vessels  are  held  aside  upon  the  dorsal  and  plantar  surfaces  with  a  periosteal 
elevator  and  retractor,  and  with  a  narrow-bladed  saw  or  a  chisel  a  wedge-shaped 
section  is  removed  with  a  lion-jaw  forceps  from  the  tarsus,  irrespective  of  the 
individual  bones  involved,  sufficient  in  size  to  allow  of  the  correction  of  the  de- 
formity. This  section  wUl  include  a  portion  of  the  os  calcis  and  a  portion  of 
the  cuboid — the  entire  cuboid  or  even  a  portion  of  the  fifth  metatarsal  bone 
being  removed  in  the  severest  cases.  The  tendons,  if  any  have  been  divided, 
should  be  united  with  silk  or  chromicized  catgut,  the  vessels  secured,  a  rubber 
drainage-tube  inserted,  and  the  wound  partially  closed  with  wire  sutures. 
A  full  aseptic  dressmg  is  then  applied.  The  foot  is  then  secured  in  a 
plaster-of-Paris  dressing  or  some  suitable  retentive  apparatus.  The  strictest 
aseptic  precautions  are  essential  to  success  and  the  safety  of  the  patient,  and 


Fig.  6oi. — Astragalectomy.     Right,  Foot  showing  Result. 


Fig.  602. — Same  as  Fig.  601,  Left  Foot. 


TALIPES,  OR  CLUB-FOOT. 


785 


during  the  subsequent  treatment  care  should  be  taken  to  keep  the  wound 
aseptic. 


Fig.  603.— Before  P^OKCiBLE  Correction.    Front  Fig.  604.— Before  Forcible  Correction.     B.\ck 

View.  View. 


Fig.  605. — Same,  showing  Result  of  Forcible  Correction. 


These    two    operative    procedures,  in    addition    to    tenotomy  and    open 
incision,  are  all  that  are  required  even  in  the  most  severe  cases,  and  while  in 


786 


ORTHOPEDIC  SURGERY 


many  cases  they  offer  a  means  of  quickly  and  brilliantly  correcting  very  severe 
deformities,  their  field  of  application  should  always  be  restricted,  and  in  no  in- 
stance should  they  be  undertaken  unless  the  surgeon  is  confident  that  aseptic 
measures  can  be  faithfully  enforced.  The  relative  merits  of  astragalectomy 
and  wedge-shaped  tarsectomy  have  given  rise  to  much  discussion,  which  has 
resulted  in  the  substitution  of  astragalectomy  and  other  methods  for  wedge- 
shaped  tarsectomy.     The  objections  to  the  latter  may  be  briefly  stated  as  follows : 

It  shortens  the  outer  side  of  the  foot. 

It  impairs  the  form  of  the  foot,  the  stability,  mobility,  and  usefulness  of 
the  osseous  arch,  and 

It  exposes  to  infection  an  extensive  surface  of  cancellous  tissue. 

The  objections  to  the  cutting  operations  upon  the  bones  in  general  (resec- 
tions of  the  tarsus)  may  be  briefly  stated  as  follows: 


Fig.  606. — McKenzie  Club-foot  Weench  Applied. 


1.  Resection  as  an  operation  is  not  free  from  risk. 

2.  Resection  removes  all  chance  of  future  restoration  by  orthopedic  treat- 
ment. 

3.  Resection  is  unjustifiable  except  in  persistently  painful  club-foot  in 
an  old  subject,  where  all  orthopedic  treatment  has  failed,  and  where  it  (resection) 
may  be  employed  in  preference  to  amputation. 

In  conclusion,  excision  of  the  tarsus  should  never  be  postponed  before  the 
fifth  year,  and,  preferably,  from  the  twelfth  to  the  fourteenth  year,  and  where 
possible  enucleation  of  the  astragalus  should  have  the  preference  over  all  other 
bone-cutting  operations. 

Brisement  force. — Under  this  title  are  included  all  operations  which 
aim  at  the  immediate  forcible  restoration  of  the  foot,  either  by  the  hand  or  power- 


TALIPES,  OR  CLUB-FOOT. 


7S7 


ful  instruments.  It  is  necessary  in  all  cases  to  employ  an  anesthetic,  to  econo- 
mize time  and  save  the  patient  much  suffering.  It  is  remarkable  how  much 
can  be  accomplished  by  manual  means  alone,  but  when  great  force  is  to  be 
applied,  the  club-foot  wrenches  of  Thomas,  Gibney,  and  McKenzie,  the  club- 
foot stretchers  of  Morton  or  Bradford,  or  the  club-foot  machine  of  Phelps,  should 
be  employed.  The  objection  to  the  wrenches  is  the  limited  application  of 
force  and  the  diihculty  of  rapid  removal  of  the  apparatus  after  the  reduction 
is  accomplished.  The  Bradford  stretcher  has  this  advantage  over  the  Morton 
apparatus,  that  the  force  is  applied  by  screw  power,  and  does  not  yield  as  do 


Fig.  607. — Line  of  Incision  anx>  Position  of 
Foot  after  Phelps'  Operation  (McKenzie). 


Fig.  60S. — Position  of  Foot  after  Phelps' 
Operation,  showing  Lakge  Bursa  on  Outer 
Side  of  Foot  (McKenzie). 


the  leather  straps  of  the  former.  The  Phelps  machine  has  the  advantage  of 
being  adapted  to  apply  any  amount  of  force  from  a  single  pound  to  a  ton. 
The  chief  objections  urged  against  all  these  methods  of  forcible  restoration  are 
the  supposed  risks  incurred — the  sloughing  of  the  skin,  the  rupture  of  the 
ligaments,  and  the  breaking  of  bones.  Experience  in  osteoclasy,  however, 
proves  that  these  fears  are  more  theoretic  than  real.  The  pressure  applied  to 
the  skin  is  so  momentary  that  sloughs  seldom  occur,  and  the  ruptured  and 
stretched  tendons  readily  heal  in  the  fixed  apparatus  subsequently  applied: 
fractures  seldom  or  never  occur. 


788 


ORTHOPEDIC  SURGERY 


Open  Incision. — In  selected  cases,  where  the  skiagraph  shows  that  there 
is  no  bony  interference  with  the  replacement  of  the  astragalus  in  its  normal  posi- 
tion, the  operation  of  Phelps  is  to  be  recommended.  After  excluding  all  cases 
which  by  manipulation  or  force  can  immediately,  or  in  a  reasonable  length  of 
time,  be  restored,  the  following  rules  should  be  followed:  "Cut  the  contracted 
parts  as  they  first  offer  resistance,  cutting  in  the  order  of  those  parts  which  first 
contracted  when  the  deformity  was  produced.  The  operator  will  then  proceed, 
after  strong  manipulation  or  force  is  applied  with  a  club-foot  machine  or  hands, 
to  subcutaneously  divide  the  tendo  Achillis.     //  the  skin  is  not  short,  subcutane- 


September,  1890.  May  4,  1891.  May  9,  iS 

Fig.  609. — Showing  Result  in  Phelps'  Operation  (McKenzie). 


ous  tenotomy  in  the  sole  of  the  foot  will  usually  suffice.  //  the  skin  is  short,  an 
open  incision  one-fourth  the  distance  across  the  foot  can  be  made,  beginning 
directly  in  front  of  the  inner  malleolus  and  carried  down  to  the  inner  side  of 
the  neck  of  the  astragalus.  Through  this  incision  the  following  tissues  can  be 
cut,  if  they  offer  strong  resistance,  in  the  order  given:  (a)  Tibialis  posticus; 
(b)  division  of  abductor  pollicis;  (c)  division  of  plantar  fascia  through  the  wound ; 
(d)  division  of  flexor  brevis  muscle;  (e)  division  of  long  flexors;  (/)  division  of 
deltoid  ligament  or  its  branches." 

The  parts  are  thoroughly  prepared  for  the  operation,  an  Esmarch  bandage 
is  applied,  the  wound  is  thoroughly  irrigated  with  bichlorid  solution,  i  :  2000, 


TALIPES,  OR  CLUB-FOOT.  789 

during  the  operation,  and  a  full  antiseptic  dressing  is  applied  before  the  bandage 
is  removed,  the  foot  being  subsequently  slung  to  a  nearly  perpendicular  position 
for  six  hours  or  longer.  In  this  manner  Phelps  performed  i6i  operations  in 
93  cases,  the  average  age  being  six  and  a  half  years,  and  the  average  time  of  the 
healing  of  the  wound  four  weeks.  In  140  of  these  cases,  117  healed  by  blood- 
clot  organization,  4  by  catgut  dressing  in  the  wound,  and  19  were  failures.  Four 
months  after  operating  the  feet  were  all  straight,  but  out  of  140  cases  traced  after 
one  year,  10  cases  were  found  relapsed,  or  partially  so,  ftrom  neglect.  In  these 
cases  there  were,  in  all,  17  osteotomies  performed. 

Amputation. — In  the  severer  forms  of  club-foot,  especially  when  com- 
plicated with  bursitis  and  extensive  ulceration,  the  individual  is  rendered  prac- 
tically helpless,  and  relief  is  sometimes  sought  in  amputation  of  the  affected 
parts.  Operations  of  this  kind  at  the  present  time  are  exceedingly  rare,  since 
with  improved  orthopedic  measures  even  the  most  severe  cases  may  now  be 
rendered  more  or  less  useful. 

VARIETIES— SPECIALLY  CONSIDERED. 
As  pointed  out  before,  the  purely  primitive  forms  are  so  rare  that  writers 
have  usually  considered  the  compound  varieties  under  the  simple  forms,  but  to 
avoid  confusion,  which  otherwise  occurs  where  this  plan  is  followed,  each  variety 
will  be  separately  considered,  especially  concerning  its  morbid  anatomy  and 
pathology. 

Simple  Forms  of  Club-foot. 
Talipes  Varus. 

Synonyms. — English,  Supination  Contracture;  Adduc- 
tion Contracture.  German,  Klumpfuss.  French,  Pied-bot 
Varus.  Italian,  Piede  torto;  Storto  del  piede.  Spanish,  Pie 
truncado. 

As  a  pure  pes  varus  this  variety  of  club-foot  is  one 
of  the  rarest,  but  as  a  part  of  the  congenital  equino-varus  ^^'^-  610.— Talipes 
it  is  exceedingly  common.  As  a  purely  primitive  type  the 
deviation  inward  of  the  anterior  portion  of  the  foot,  and  its  supination  and 
adduction,  occur  at  the  tibio-tarsal  articulation,  the  deformity  being  entirely 
upon  a  lateral  plane.  In  severe  cases  the  internal  border  is  elevated,  the 
sole  curved  inward,  and  the  external  border  depressed.  It  may  here  be  re- 
marked that  in  most  infants  at  birth  there  exists  a  tendency  to  varus,  which 
disappears  as  the  child  attempts  to  walk. 


790  ORTHOPEDIC  SURGERY. 

The  morbid  anatomy  of  this  rare  affection  wUl  be  described  under  the  com- 
pound form — equino-varus. 

Talipes  Valgus. 

Synonyms. — English,  Flat-foot;  Splay-foot.  French,  Pied-bot  Valgus. 
German,  Plattfuss. 

This  variety  occurs  both  as  a  congenital  and  an  acquired  affection,  the  former 
being  rare  and  usually  of  the  compound  variety — equino- valgus ;  the  latter  being 
very  common,  occurring  also  as  a  compound  form — calcaneo-valgus.  The 
frequency  of  this  form  is  well  shown  in  the  interesting  statistics  collected  by 
Hoffa  in  the  Miinchener  Poliklinik.  Of  the  17,619  surgical  affections,  338,  or 
0.49  per  cent.,  were  fiat-foot;  of  1444  deformities,  338,  or  23.41  per  cent.,  were 
flat-foot.  Out  of  235  cases,  he  found  that  10,  or  4.5  per  cent.,  were  congenital, 
and  225,  or  95.7  per  cent.,  were  acquired.  Of  these  225  cases,  11,  or  4.9  per 
cent.,  were  traumatic;  7,  or  3.1  per  cent.,  were  paralytic;  7,  or  3.1  per  cent., 
were  rachitic;    200,  or  88.9  per  cent.,  were  static. 

Flat-foot  often  coexists  with  lateral  curvature  as  cause  and  effect. 

Congenital  Valgus. 

As  a  congenital  affection,  in  its  mildest  form  it  is  often  found  at  birth, 
but  seldom  in  such  a  degree  as  to  be  considered  pathologic.  It  is,  moreover, 
a  well-established  fact  that  all  infants  on  commencing  to  walk  are  flat-footed, 
and  do  not  acquire  a  perfect  plantar  arch  until  they  have  exercised  some  time 
and  the  leg  muscles  have  become  developed. 

Of  well-marked  congenital  valgus,  Adams  found  42  cases  in  764  patients 
afflicted  with  congenital  deformity  of  the  feet,  and  Kustner  found  13  cases  of 
well-marked  valgus  in  150  newborn  infants  taken  consecutively. 

The  statement  that  most  infants  have  fiat-foot,  with  a  tendency  to  varus, 
may  seem  paradoxic,  but  when  it  is  understood  that  the  varus  relates  to  the 
inverted  position  of  the  anterior  portion  of  the  foot,  and  the  valgus,  or  flat-foot, 
to  the  sole  of  the  foot,  the  correctness  of  the  statement  will  be  evident. 

Numerous  observers  have  noted  that  at  birth  most  infants  have  a  distinct 
arch,  which  persists  for  eighteen  months,  after  which  a  breaking-down  of  the 
arch  occurs,  but  is  followed  in  a  few  years  by  its  restoration. 

As  a  persistent  congenital  deformity  three  degrees  of  severity  have  been 
established,  according  to  the  amount  of  outward  deviation  of  the  anterior  part 
of  the  foot — slight,  intermediate,  and  severe.     In  the  severer  forms  the  entire 


TALIPES,  OR  CLUB-FOOT.  791 

sole  of  the  foot  rests  upon  the  ground,  the  internal  border  is  lengthened,  and 
the  external  border  shortened  and  creased  over  the  medio-tarsal  articulation, 
or  the  foot  may  even  be  rotated  outward,  the  sole  being  everted  and  turned 
backward. 

From  dissections  made  of  congenital  valgus  the  pathologic  condition  of 
the  foot  has  been  noted.  According  to  these,  the  astragalus  is  tUted  down- 
ward and  forward,  the  head  depressed  on  its  outer  side,  its  upper  part 
projecting  from  the  rotation  of  the  scaphoid,  and  the  changed  direction  of 
the  astragalo-scaphoid  articulation.  The  tuberosity  of  the  os  calcis  is 
short  and  thrown  forward.  The  cuboid  and  scaphoid  are  rotated  inward. 
The  malleoli  are  depressed,  the  inner  one  resting  in  severe  cases  upon  the 
ground. 

Acquired  Valgus. 

Synonyms . — Splay-foot ;   Flat-foot. 

As  an  acquired  affection  iiat-foot  is  most  common  from  infancy  to  abdoles- 
cence,  seldom  becoming  a  serious  deformity  until  the  latter  period,  and  always 
occurring  in  one  of  two  forms — either  as  pes  valgus  paralytica,  resulting  from 
poliomyelitis  anterior,  or  as  pes  valgus  acquisitus,  resulting  from  simple 
muscular  relaxation,  as  seen  in  association  with  rachitis  or  as  a  sequel  of 
bums,  traumatism,  osteitis  of  the  tarsus,  or  ankle-joint  disease. 

Three  degrees,  or  stages,  as  in  the  congenital  variety,  have  usually  been 
recognized — mUd,  medium,  and  severe. 

1.  The  mild  variety  is  that  in  which  the  deformity  is  present  during  the 
erect  position  only. 

2.  The  medium  variety  is  that  in  which  the  deformity  is  present  at  all  times, 
but  is  not  especially  marked. 

3.  The  severe  variety  is  characterized  by  an  aggravation  of  all  the  symp- 
toms to  a  marked  degree. 

Numerous  theories  have  been  advanced  as  to  the  mode  of  production  of 
flat-foot.  The  muscles,  tendons,  ligaments,  bones,  fascias,  and  even  an  im- 
proper mechanical  construction,  have  each  been  considered  the  chief  factors 
in  its  production. 

Some  authorities  believe  that  the  normally  constructed  human  foot  is 
incorrect  anatomically,  saying  that  the  lower  end  of  the  tibia  is  placed  too 
much  toward  the  inner  border  of  the  foot,  and  claiming  this  as  the  primary  cause. - 
Others  believe  that  atony  of  the  plantar  fascia  and  the  tarsal  interosseous  liga- 


792  ORTHOPEDIC  SURGERY. 

ments  were  responsible,  while  stUl  others  consider  it  due  to  a  rotation  of  the 
astragalus  inward  and  pressure  atrophy  of  the  bones;  to  muscular  contraction, 
first  of  the  extensors  and  then  of  the  pronators;  or  to  muscular  insufficiency 
and  body-pressure,  an  explanation  first  proposed  by  Duchenne,  who  con- 
sidered the  peroneus  longus  particularly  at  fault. 

Of  these  theories,  the  last  has  always  appeared  to  me  the  most  satisfactory: 
that  it  is  a  muscular  affection  from  the  first.  Thus,  muscular  relaxation,  either 
from  debility  or  paralysis  of  the  peroneus  longus,  leads  to  an  improper  distri- 
bution of  the  body-weight  upon  the  tarsal  arches,  which,  by  undue  pressure 
upon  the  interosseous  ligaments,  especially  the  inferior  calcaneo-scaphoid  and 
calcaneo-cuboid  ligaments  and  plantar  fascia,  induces  their  subsequent  relaxation, 
stretching,  and  obliteration  of  the  normal  arch. 

In  some  instances  the  inflammatory  variety  follows  systemic  infections, 
especially  typhoid  fever  and  gonorrhea. 

The  symptoms  differ  in  the  two  varieties — pes  valgus  acquisitus  and  pes 
paralytica — but  in  each  are  characteristic. 

(a)  Pes  Valgus  Acquisitus. — Synonyms:  English,  Talipes  Valgus 
Spurius;  Inflammatory  or  Acute  Flat-foot ;  Tarsalgia  of  Adolescents;  Contract- 
ured  Static  Flat-foot.  Italian,  Piede  da  pianezza;  Piede  spianato.  Spanish, 
Pie  piano.   German,  Pes  valgus.  French,  Pied  plat  valgus  acquis  de  I'adolescence. 

Patients  suffering  from  pes  valgus  acquisitus  have  an  attitude  and  walk 
that  are  characteristic.  They  stand  with  the  feet  everted,  resting  on  the  inner 
side  of  the  sole,  with  the  knees  in  a  flexed  valgoid  position,  and  walk  with  a 
difficult,  heavy  gait,  the  knees  flexed  and  the  feet  placed  everted  flat  upon  the 
ground  in  an  uncertain,  careful  manner.  Such  patients  have  an  expression  of 
anxiety,  tire  easUy,  and  complain  of  great  pain  of  a  dull,  aching  character,  or 
sharp,  excruciating  in  nature,  about  the  inner  malleolus,  instep,  or  ball  of  the 
great  toe,  accompanied  in  some  cases  with  swelling.  The  pain  is  sometimes 
very  acute.  I  have  known  individuals  to  fall  in  the  street  from  the  pain  of  this 
affection  and  to  be  taken  to  the  hospital  and  treated  for  sprains.  The  bilateral 
character  of  this  aft'ection  should  serve  to  distinguish  it.  On  inspection  the 
external  appearance  varies  with  the  degree.  In  the  mild  variety  the  plantar  arch 
is  depressed,  the  inner  malleolus  lowered  and  prominent;  the  foot  is  cold,  bluish, 
and  perspires  freely,  and  the  angle  of  deflection  is  found  reduced  from  thirty- 
four  degrees  normal  to  about  twelve  degrees  in  mild,  to  eight  degrees  in  severe, 
cases.  The  patient  cannot  raise  himself  on  his  toes,  but  the  deformity  can  be 
readily  corrected  by  manual  pressure. 


TALIPES,  OR  CLUB-FOOT. 


793 


In  the  medium  variety  all  these  conditions  are  exaggerated,  the  foot  is 
completely  flattened  and  somewhat  everted,  the  inner  side  presents  two  promi- 
nences below  and  anterior  to  the  internal  malleolus,  the  head  of  the  astragalus, 
and  the  tubercle  of  the  scaphoid;  and  on  taking  an  outline  the  angle  of  de- 
flection is  found  reduced  to  probably  eight  degrees.  The  pain  is  common 
about  the  inner  lower  portion  of  the  astragalus,  and  may  be  so  severe  as  to 
render  exercise  intolerable.  Sometimes  there  is  a  tender  spot  in  the  plantar 
fascia  over  the  calcaneo-scaphoid  articulation.  The  arch  can  still  be  restored, 
and  the  deformity  is  not  prominent. 

In  the  severe  variety  the  foot  is  more  everted,  making  an  angle  of  deflection 
in  severe  cases  as  low  as  five  degrees.  This  is  due 
to  functional  paresis  of  the  peroneus  longus,  and 
increased  reflex  contraction  of  the  peroneus  brevis, 
tertius,  and  extensor  communis  digitorum.  The 
pain  is  increased  by  the  unbalanced  action  of 
muscles,  giving  a  painful  spot  at  the  base  of  the 
flrst  metatarsal  bone;  direct  pressure  upon  the 
ligaments  causes  points  of  tenderness  to  develop 
over  the  calcaneo-cuboid  and  astragalo-scaphoid 
articulations;  and  from  direct  pressure  upon  the 
plantar  nerves  pain  is  referred  to  their  distribu- 
tion. Fibrous  and  osseous  changes  have  occurred, 
and  so  the  arch  cannot  be  restored  without  some 
operative  procedure. 

The  pathology  of  the  affection  was  for  some 
time  obscure,  especially  of  the   non-paralytic  val- 
gus,   it    being    supposed    at    one    time    to  be  in- 
flammatory.    Such  cases  have  frequently  been  mistaken  and  actively  treated 
for   inflammatory  lesions  of  the  bones  or  ligaments;    complete  inflammation, 
with  effusion  of  lymph,  serum,  or  pus,  never  occurs,  however.     All  the  inflam- 
matory symptoms  are  simply  the  result  of  pressure. 

The  extensors,  particularly  the  peroneus  longus,  from  some  cause,  become 
relaxed.  This  is  followed  by  stretching  and  elongation  of  the  plantar  muscles 
and  tendons,  the  long  and  short  plantar  ligaments,  the  calcaneo-cuboid  and  astra- 
galo-scaphoid ligaments,  and  the  plantar  fascia,  and  a  giving  way  of  the  inner 
antero-posterior  arch.  The  astragalus  is  pushed  dovmward,  forward,  and 
inward;  the  scaphoid  is  rotated,  the  internal  surface  do\\Tiward  and  the  external 


Fig.  6ii. — Medium  Degree  of 
Flat-foot. 


794  ORTHOPEDIC  SURGERY. 

surface  upward;  the  ligaments,  generally  on  the  inner  and  plantar  surfaces 
of  the  bones,  are  stretched,  the  joint  surfaces  separated  on  the  plantar  and 
crowded  together  on  the  dorsal  aspect.  This  may  become  so  great  that  the  bones 
entering  into  the  medio-tarsal  (Chopart's)  joint  divide,  the  anterior  portion 
resting  upon  the  ground,  the  posterior  portion  being  dra^vn  up  by  the  extensors 
of  the  foot  so  that  the  heel  does  not  touch  the  floor,  making  the  so-called  "canoe- 
shaped  sole."  The  articular  surfaces  become  eroded  from  the  contmued 
pressure,  and  osseous  ankylosis  renders  the  deformity  permanent.  The  diag- 
nosis in  many  cases  can  readily  be  made,  but  in  others,  especially  the  inflam- 
matory variety,  with  which  we  are  most  concerned,  very  careful  attention  is 
required  to  avoid  confounding  it  with  other  conditions. 

From  the  congenital  forms  of  valgus  it  can  be  distinguished  by  the  latter 
always  being  bilateral  and  the  peroneus  responding  to  electric  stimulus.  (The 
slight  normal  tendency  to  flat-foot  observed  in  infants  has  already  been  referred 
to.)  Its  occurrence  about  the  period  of  adolescence,  the  previous  history  of 
rheumatism,  knock-knee,  bow-legs,  lateral  curvature,  traumatism,  bone  or  joint 
disease,  all  should  be  carefully  inquired  into. 

It  is  most  commonly  mistaken  for  rheumatism,  of  which  it  may  be  a  sequel, 
and  for  inflammatory  conditions  of  the  tarsal  and  metatarsal  joints  or  ligaments. 
Its  angle  of  deflection  determined  from  the  outline  will  be  the  best  single  symptom 
to  distinguish  it  from  the  former,  and  the  same  with  reflex  muscular  contraction, 
or  a  collection  of  inflammatory  fluid,  from  the  latter.  The  lesions  from  which 
it  would  be  most  difiicult  to  distinguish  it  are  the  early  stages  of  perforating 
ulcer,  and  such  neuropathies  as  Charcot's  joint  disease.  From  these  in  the 
earlier  stages  a  differential  diagnosis  cannot  be  made,  but  the  subsequent  course 
would  soon  decide  the  true  nature  of  the  affection. 

The  prognosis  will  depend  on  the  cause  and  general  condition  and  surround- 
ings of  the  patient  and  degree  of  the  deformity.  If  advice  is  sought  early,  and 
the  disease  is  still  in  the  first  or  even  second  degree,  the  prospects,  under 
appropriate  treatment,  of  great  improvement  or  even  complete  cure  are  good. 
Certainly  entire  relief  of  pain  may  be  expected.  If,  however,  ligamentous  or 
osseous  ankylosis  has  occurred,  some  relief  may  yet  be  hoped  for,  but  resort 
must  be  had  to  brisement  force,  or  tarsectomy,  before  the  deformity  can  be 
overcome. 

(b)  Pes  Valgus  Paralytica. — As  a  result  of  infantile  paralysis  (poliomye- 
litis anterior)  paralytic  flat-foot  is  favored  by  the  flail-like  condition  of  the  foot 
upon  the  ankle-joint,  the  relaxed  ligaments,  and  the  action  of  gravity,  and  is 


TALIPES,  OR  CLUB-FOOT.  795 

aggravated  by  bearing  the  body-weight  upon  the  foot  in  its  wealiened  everted 
position.  Neglected  cases  grow  progressively  worse  until  the  severest  grades 
are  reached.  This  tendency  is  increased  by  the  action  of  those  muscles  which 
are  antagonistic  to  the  paralyzed  muscles. 

These  deformities  gradually  becor.  e  permanent  and  are  not  dependent 
upon  tonic  retraction;  nor  is  the  shortening  of  the  muscles  due  to  contraction, 
but  to  the  growth  of  the  limb,  the  foot  remaining  in  its  deformed  position. 
This  is  particularly  true  of  the  peronei  group  of  tendons,  which  often  stand  out 
prominently  behind  the  external  malleolus.  The  walk  of  patients  suffering 
with  paralytic  valgus  is  peculiar  and  characteristic.  The  everted  foot  is  thrown 
outward  and  forward,  describing  the  arc  of  a  circle,  the  center  of  which  cor- 
responds to  the  position  of  the  other  foot.  The  foot  rolls  inward  and  the  body 
sinks  dovraward  on  that  side  as  the  superincumbent  weight  is  thrown  upon  it. 
The  sound  foot  is  brought  forward  and  the  act  is  repeated,  giving  to  the  patient 
an  oscillating  progression.  Aside  from  the  general  paralysis  of  the  muscles 
the  morbid  anatomy  of  this  variety  of  fiat-foot  is  identical  .with  that  of  the  pes 
valgus  acquisitis,  and  need  not  be  here  repeated. 

The  prognosis  is  influenced  by  the  degree  of  the  deformity  and  the  amount 
of  paralysis.    The  paralyzed  muscles  cannot  be  restored,  but  the  position  and 
usefulness  of  the  foot  can  be  much  improved  by  appro- 
priate measures.      The  electric  reactions  of  the  muscles  ,  i 
establish  the  diagnosis  of  the  deformity.                                                1  | 

Talipes  Equinus. 

Synonyms. — French,  Pied-bot  Equine.  German, 
Spitzfuss;  Pferdefuss.  /^aZi'a??,  Talipe  equina.  Spanish, 
Talipes  equina. 

As  a  primitive  form  talipes  equinus  may  be  either 
acquired  or  congenital.  The  former  as  a  paralytic  de- 
formity is  common,  but  the  latter  is  very  infrequent,  its 
very  existence  being  sometimes  denied.  ^^°' EoTOros"""^^ 

The  most  common  causes  of  acquired  equinus  are 
infantile  spinal  paralysis,  spastic  paralysis,  post-hemiplegic  contractions,  pro- 
tracted decubitus,  as  typhoid,  typhus,  etc.;  inflammation  of  the  ankle-joint; 
wounds,  burns,  cicatrices,  abscesses,  etc.,  of  the  calf  of  the  leg;  hysteria,  or 
neuromimesis.  Compensatory  equinus  occurs  from  a  shortening  of  the  extrem- 
ity from  any  cause,  as  hip  disease,  fracture,  etc.     The  foot  is  extended  upon  the 


796  ORTHOPEDIC  SURGERY. 

leg,  varying  in  degree  from  a  condition  in  which  the  foot  is  a  trifle  over  90 
degrees  in  relation  to  the  leg,  to  one  in  which  the  foot  is  in  a  continuous  line 
with  the  leg  or  even  beyond  180  degrees.  According  to  the  degree  of  deformity 
the  external  appearance,  the  walk  of  the  patient,  and  the  structural  changes 
vary  greatly.  In  the  mUdest  form  the  general  appearance  of  the  foot  is  but 
little  changed.  In  the  severer  grades  the  arch  is  increased,  the  plantar  surface 
diminished,  the  plantar  fascia  contracted,  the  toes  are  extended,  the  calf 
muscles,  particularly  in  the  paralytic  forms,  are  shrunken.  \\Tien  the  foot  is 
retroverted,  the  skin  of  the  dorsum  becomes  callous,  thickened,  and  inflamed 
from  walking  upon  it. 

In  mild  cases  locomotion  is  but  little  affected,  the  increased  length  of  the 
extremity  being  overcome  by  flexion  of  the  knee.  The  individual  walks  upon 
the  ball  of  the  foot  and  toes  alone,  dragging  the  limb  or  swinging  it  for^vard  by 
circular  movements.  When  the  foot  is  retroverted,  it  becomes  practicallv 
useless. 

The  morbid  anatomy  of  equinus  consists  essentially  of  a  contraction  of  the 
superficial  extensor  muscles  and  a  relaxation  or  paralysis  of  the  flexors  of  the 
leg.  The  bones  of  the  foot  may  be  unaltered,  or  they  may  be  and  usually  are 
much  deformed  in  severe  cases.  The  astragalus  projects  prominently  on  the 
dorsum  of  the  foot,  the  head  projecting  free  above  the  astragalo-scaphoid 
articulation,  and  the  scaphoid  being  subluxated.  The  articular  surface  of  the 
astragalus  extends  further  posteriorly  than  normal.  The  calcaneo-cuboid  artic- 
ulation is  likewise  affected,  the  anterior  portion  of  the  os  calcis  being  sub- 
luxated.  The  ligaments  on  the  plantar  surface  and  the  plantar  fascia  become 
contracted;   those  on  the  dorsal  surface  become  elongated. 

The  diagnosis  should  always  be  made  with  the  knee  extended,  as  this  in- 
creases the  deformity.  The  previous  history  is  important  in  determining  the 
cause. 

The  prognosis  in  general  is  good,  particularly  if  osseous  changes  have  not 
occurred. 

Talipes  Calcaneus. 

Synonyms. — French,  Pied-bot  Talus;  Pied-bot  Calcanien.  German. 
Hakenfuss.     Italian,    Talipe   calcanea.     Spanish,    Talipes    calcanea. 

This  deformity,  the  direct  opposite  of  the  equinus,  occurs  as  both  a  con- 
genital and  an  acquired  affection,  but  as  a  purely  primitive  form  it  is  the  rarest 
of  all   the  varieties.     Associated  with  valgus — as  calcaneo-valgus — it  is  quite 


TALIPES,  OR  CLUB-FOOT. 


797 


common.     The  deformity  consists  of  a  flexion  of  the  foot  upon  the  leg  at  the 
tibio-tarsal  articulation. 

As  a  congenital  affection  it  may  be  the  remains  of  the  normal  intrauterine 
position  of  flexion,  or  may  depend  upon  intrauterine  disturbances.  According 
to  Adams,  it  is  common  in  breech  cases  with  extended  limbs.  In  congenital  cases 
the  foot  is  observed  to  be  flexed  upon  the  leg,  and  on  attempting  to  walk,  only 
the  heel  comes  in  contact  with  the  ground.  The  dorsum  of  the  foot  is  shortened 
and  wrinkled.  The  plantar  surface  later  becomes  somewhat  concave  (pes  cavus) 
from  the  action  of  the  flexors  of  the  foot  and  of  the  deep  extensors  of  the  leg. 

According  to  the  degree  of  deformity,  three  grades  of  congenital  calcaneus 
have  been  described,  depending  upon  whether  the  foot  forms  a  right  angle  or 
an  acute  angle  with  the  leg,  or  whether  its  dorsum 
touches  the  anterior  surface  of  the  leg. 

Considering  the  amount  of  deformity,  the  tarsal 
bones  are  not  much  altered,  the  changes  being  prin- 
cipally in  the  articular  surfaces.  The  astragalus 
seems  to  be  displaced  backward  toward  the  poste- 
rior part  of  the  os  calcis,  and  rotated  backward  so 
that  its  neck  comes  in  contact  with  the  inferior  tibio- 
fibular surfaces,  the  anterior  part  of  its  upper  articu- 
lar surface  lying  uncovered  behind  the  tibia.  The 
posterior  part  of  the  os  calcis  may  be  bent  down- 
ward and  the  tubercle  displaced  slightly  forward. 
The  superficial  extensors — gastrocnemius,  soleus, 
and  plantaris — are  usually  atrophied;    the  deep  muscles  are  usually  normal. 

As  an  acquired  affection  it  frequently  results  from  infantile  paralysis, 
caries  of  the  ankle-joint,  wounds,  burns,  cicatrices,  rupture  of  the  tendo  Achillis, 
rapid  stretching  of  the  tendo  Achillis  after  tenotomy,  etc.  Cases  are  also  re- 
corded from  pathologic  displacement  of  the  epiphyses,  following  osteomyelitis, 
and  from  spontaneous  separation  of  the  epiphysis. 

In  the  acquired  form,  particularly  the  paralytic  variety,  the  relation  of  the 
foot  to  the  leg  is  much  the  same;  but  there  is  usually  a  greater  tendency  to  cavus, 
from  the  retraction  of  the  plantar  muscles  and  fascia.  The  extensor  proprius 
poUicis,  extensor  longus  digitorum,  tibialis  anticus,  and  sometimes  the  peroneus 
tertius,  are  all  involved.  The  leg  and  foot  are  much  atrophied,  and  the  skin 
cold  and  purplish.  The  bones  are  more  displaced,  and  the  ligaments  are 
lengthened  posterior  to  the  ankle. 


Fig.  613. — Talipes  Calcaneus. 


798  ORTHOPEDIC  SURGERY. 

There  is  no  difficulty  about  the  diagnosis  of  this  deformity,  and  the  prog- 
nosis in  the  congenital  cases  is  excellent.  The  acquired  variety  can  be  much 
improved  by  suitable  mechanical  means,  but  the  paralytic  nature  of  the  majority 
of  these  cases  precludes  the  possibility  of  absolute  cure. 

Artificial  Calcaneus. 

The  deformed  feet  of  Chinese  women  bear  a  close  resemblance  to,  if  not  an 
exact  identity  with,  this  deformity,  especially  in  its  severer  forms,  and  have 
been  described  as  artificial  calcaneo-cavus. 

This  artificial  deformity  is  effected  early  in  life,  about  the  fifth  year,  by  an 
ingenious  method  of  foot-binding,  peculiar  to  the  Chinese  proper  and  not  ac- 
cepted by  the  Manchu  Tartars,  or  reigning  power.  The  process  of  production 
has  been  well  described  by  Harris,  to  whom  we  are  indebted  for  the  following: 

"There  are,"  he  says,  "three  points  to  be  gained  by  the  binding,  which 
collectively,  and  under  the  influence  of  an  atrophic  action,  the  result  of  defective 
nutrition,  make  the  feet  small,  and  give  the  skin  of  both  feet  and  legs  a  shriveled 
appearance.  The  first  step,  and  that  to  which  the  parts  make  the  least  resistance, 
is  the  bending  of  the  four  smaller  toes  under  the  sole  of  the  foot,  and  the  narrow- 
ing of  the  parts  supported  by  the  metatarsal  bones.  The  second  step  is  best 
accomplished  in  early  childhood,  when  the  tarsal  bones  appear  to  move  with 
a  joint-like  flexibility  upon  each  other,  and  consists  in  a  forcing  together  of  the 
plantar  portions  of  these  bones,  whereby  they  are  subjected  to  a  continuous 
pressure,  and  in  an  opening,  or  rather  attempt  at  opening,  of  the  articular 
crevices  of  the  instep,  keeping  their  ligaments  constantly  tense  at  the  same 
time.  The  third  step  is  the  last  to  be  accomplished,  and  can  only  be  completed 
in  the  young  subject.  The  os  calcis,  with  the  astragalus,  is  forced  downward 
until  the  heel  is  vertical  and  its  bone  on  a  line  with  those  of  the  leg.  The  calcis 
is  rounded  in  form,  losing  its  processes,  which  are  so  prominent  in  the  normal 
bone;  and  its  anterior  articulating  face  is  brought  up  near  the  high,  instep- 
like arch  just  in  front  of  the  ankle-joint,  while  at  the  same  time  the  point  of 
attachment  of  the  tendo  Achillis  is  made  the  base  upon  which  the  girl  stands 
when  erect,  and  steps  in  walking." 

The  anatomic  changes  are  well  shown  both  externaUy  and  by  dissection. 
The  characteristics  are  the  bending  under  of  the  four  smaller  toes,  especially 
the  disproportionate  size  and  length  of  the  fifth  toe,  which  reach  to  or  even  beyond 
the  central  line  of  the  sole;  the  deep  indentation  of  the  sole  at  the  medio-tarsal 
articulation,  which,  when  perfected,  amounts  to  a  mere  fissure  an  inch  and  a 


TALIPES,  OR  CLUB-FOOT.  799 

half  deep;  the  vertical  direction  of  the  os  calcis,  and  its  square  base;  the  height 
and  prominence  of  the  instep;  the  posterior  position  of  the  external  ankle; 
and  the  diminutive  circumference  of  the  anlde. 

Dissections  have  been  made  and  almost  every  museum  possesses  dried 
specimens  and  casts  of  this  interesting  deformity. 


Compound  Forms  of  Club-foot. 
Talipes  Equino-varus. 

Synonyms. — English,  Club-foot;  Reel-foot;  Stump-foot;  Pes  Contortus. 
German,  Klumpfuss.  French,  Pied-bot  Varus.  Italian,  Piede  de  storto. 
Spanish,  Talipes  equinovara. 

This,  the  most  common  variety  of  club-foot,  may  be  either  congenital  or 
acquired.     It  is  the  most  frequent  of  all  the  congenital  deformities. 

The  deformity  is  threefold :  the  heel  is  elevated,  the  anterior  portion  of  the 
foot  is  adducted,  and  the  internal  border  of  the  foot  is  raised  upward. 

Three  forms  of  either  the  congenital  or  acquired  varieties  have  been  dis- 
tinguished : 

1.  Mild,  or  where  the  foot  can  still  be  brought  into  its  normal  position 
and  the  angle  between  the  foot  and  the  lower  extremity  is  greater  than  90  degrees. 

2.  Medium,  or  where  correction  is  not  possible  to  such  a  degree,  the  foot 
being  drawn  more  internally. 

3.  Severe,  or  where  it  is  impossible  to  correct  the  deformity  manually,  the 
foot  being  at  an  acute  angle  with  the  inner  surface  of  the  lower  extremity,  all 
the  tissues  on  the  inner  side  being  shortened. 

The  acquired  forms  may  result  from  one  of  three  causes:  (i)  nervous, 
either  spastic,  as  from  tetanoid  paraplegia,  spinal  sclerosis,  pseudo-hypertrophic 
paralysis;  or  paralytic,  especially  infantile  or  progressive  muscular  atrophy; 
(2)  traumatic,  such  as  fractures,  dislocations,  sprains,  etc.,  in  the  neighborhood 
of  the  tibio-tarsal  or  mid-tarsal  articulations;  (3)  articular,  from  chronic  joint 
affections  of  the  same  articulations. 

Congenital  Equino-varus. 

In  severe  congenital  equino-varus  the  anterior  portion  of  the  foot  is  turned 
inward,  the  adduction  ranging  from  40  degrees  to  63  degrees,  with  an  average 
of  about  51  degrees;  the  sole  is  directed  backward,  and  its  inner  border  directly 
upward ;  the  heel  is  small  and  misshapen ;  the  internal  malleolus  less  prominent, 


800 


ORTHOPEDIC  SURGERY 


the  external  more  prominent  than  normal  and  located  more  downward  and  back- 
ward. The  dorsum  of  the  foot  is  irregular,  through  the  prominence  of  the  head 
of  the  astragalus  and  anterior  extremity  of  the  os  calcis,  and  the  obliquity  of  the 
neck  of  the  astragalus. 

In  cases  of  greater  severity  the  inner  edge  of  the  foot  may  approximate 
the  inner  side  of  the  leg,  and  the  great  toe  is  separated  from  the  second  by  the 
contraction  of  the  extensor  pollicis  muscle. 

The    morbid  anatomy   in   congenital  equino-varus  consists  in   marked 


Fig.  614. — Talipes  Equino-vaeus  (Left)   (Bur 
rell). 


-Normal  Foot  (Right)  (Burrell). 


changes  of  all  the  structures  except  the  muscles,  which  at  birth  are  almost  always 
healthy,  but  soon  atrophy  from  disuse. 

The  OS  calcis  is  altered  both  in  form  and  position.  Its  form  in  severe  cases 
is  slightly  concave  on  the  inner  side.  Its  position  in  severe  cases  is  more  oblique, 
almost  vertical,  from  the  contraction  of  the  superficial  calf  muscles,  and  the 
anterior  extremity  is  directed  obliquely  forward  and  inward.  Its  tuberosity 
is  directed  outward  and  in  severe  cases  is  in  contact  with  the  fibula. 

The  astragalus  is  altered  in  position  and  form  and  rotated  on  an  antero- 
posterior axis.     It  is  tilted  obliquely  forward  and  downward  and  the  superior 


TALIPES,  OR  CLUB-FOOT.  801 

articular  surface  is  somewhat  displaced,  the  anterior  portion  being  prominent 
on  the  dorsum  of  the  foot.  The  lateral  facets  of  this  articulating  surface  are 
extended  from  the  ankle-joint  forward.  The  neck  of  the  bone  is  deflected 
obliquely  inward,  forming  an  obtuse  angle  with  the  body  of  the  bone,  bearing 
a  strong  resemblance  to  the  os  calcis  of  the  ape. 

While  the  normal  angle  of  deflection  amounts  at  birth  to  an  average  of  38 
degrees,  and  in  the  adult  healthy  foot  to  26I  degrees,  in  congenital  equino-varus 
it  varies  from  64  degrees  to  31  degrees,  the  average  being  49.5  degrees. 

In  consequence  of  this  obliquity  of  the  neck  of  the  astragalus  the  articular 
head  does  not  project  directly  forward,  but  in  an  antero-lateral  direction,  and 
in  severe  cases  the  surface  has  two  articular  facets  instead  of  one,  the  larger 
of  which  articulates  with  the  displaced  scaphoid. 

The  scaphoid  is  not  altered  in  form,  but  is  drawn  upward,  inward,  and 
backward  by  the  tibialis  posticus,  assisted  by  the  tibialis  anticus  and  extensor 
proprius  pollicis  muscles. 

The  cuboid  presents  no  alteration  either  in  form  or  position.  Later,  as 
the  effect  of  increased  lateral  growth,  its  shape,  as  seen  from  above,  is  quadri- 
lateral rather  than  triangular. 

The  cuneiforms  and  metatarsals  are  inverted,  but  not  otherwise  altered 
in  relation  to  one  another  or  to  the  scaphoid  and  cuboid  bones. 

The  malleoli  in  recent  congenital  cases  are  normal,  but  from  the  inward 
twisting  of  the  lower  portion  of  the  tibia,  there  is  an  apparent  deficiency  of  the 
internal  malleolus,  and  an  exaggerated  projection  of  the  external  malleolus. 

The  ligaments  are  oifly  markedly  affected  in  the  severe  grades.  In  these 
the  internal  lateral,  especially  the  deltoid  portion  of  it,  the  ligaments  on  the 
plantar  surface,  the  calcaneo-cuboid,  calcaneo-scaphoid,  and  the  plantar  fascia 
are  all  contracted.  The  severity  of  the  case  might  be  judged  by  the  ligamentous 
rigidity  rather  than  by  the  external  form,  the  ligaments  being  the  only  constant 
anatomic  hindrance  to  rectification.  The  dorsal  ligaments,  the  astragalo- 
scaphoid,  and  the  anterior  portion  of  the  capsular  ligament  of  the  ankle-joint 
are  elongated. 

The  muscles  are  at  birth  almost  always  healthy  and  retain  their  electric 
reactions.  They  are  subject  later,  in  uncorrected  cases,  to  the  atrophy  of  disuse. 
In  rare  cases  hypertrophy  of  one  or  more  muscles  has  been  found. 

The  tendons  are  always  much  displaced  and  adapted  to  the  altered  position 
of  the  bones.  A  knowledge  of  the  altered  relations  of  the  tibialis  anticus, 
tibialis  posticus,  and  tendo  Achillis  is  of  direct  practical  importance  in  per- 

52 


S02  ORTHOPEDIC  SURGERY. 

forming  tenotomy.  The  tendon  of  the  tibialis  anticus,  as  it  crosses  the  ankle- 
joint,  is  much  displaced  to  the  inner  side,  passing  in  severe  cases  obliquely 
downward   across   the   internal   malleolus. 

The  tendon  of  the  tibialis  posticus  at  the  point  usually  selected  for  its  divi- 
sion— just  above  the  malleolus — is  placed  relatively  more  for^vard  than  in  the 
normal  foot,  being  exactly  midway  between  the  anterior  and  posterior  borders 
of  the  leg  on  its  internal  aspect. 

The  tendo  Achillis,  in  consequence  of  the  lateral  obliquity  of  the  os  calcis, 
is  inclined  toward  the  external  malleolus,  and  consequently  is  further  removed 
from  the  posterior  tibial  artery  than  nomial.  The  relations  of  the  other  tendons, 
though  altered,  have  no  practical  bearing.  The  vessels  and  nerves  are  con- 
tracted on  the  internal  aspect.  This  contraction  of  the  vessels,  particularly 
the  posterior  tibial,  should  be  remembered  in  forcible  manual  rectification  of 
the  foot,  lest  the  circulation  be  arrested  or  the  artery  be  ruptured. 

In  neglected  varus  and  in  uncorrected  adult  cases  as  the  result  of  pressure 
in  walking,  the  deformity  is  ver\'  greatly  exaggerated.  The  inversion  of  the 
foot  brings  the  part  at  right  angles  to  the  leg,  the  sole  is  directed  upward  and 
backward,  the  dorsum  downward  and  forward,  the  latter  becoming  callous 
from  walking;  the  heel  is  drawn  up,  and  the  foot  is  shorter  than  its  opposite, 
from  atrophy.  A  deep  transverse  groove  marks  the  tibio-tarsal  joint,  and  a 
deep  longitudinal  groove  divides  the  sole.  The  calf  muscles  are  much  atrophied. 
There  is  slight  motion  at  the  ankle-joint,  the  feet  in  walking  being  lifted  one  over 
the  other,  a  circumstance  which  probably  gave  origin  to  the  term  "reel-foot." 

The  anatomic  changes  are  great.  The  astragalus  is  completely  vertical 
in  position,  the  neck  is  much  elongated  and  misshapen,  and  the  head  has  two 
articular  facets  at  right  angles  to  each  other.  The  os  calcis  occupies  an  oblique, 
almost  vertical  position,  its  tuberosity  being  deflected  toward  the  fibula.  The 
body  of  the  bone  is  curved,  the  convexity  being  outward. 

The  scaphoid  is  atrophied,  compressed  in  its  inner  half,  and  drawn  com- 
pletely under  the  internal  malleolus,  its  long  axis  being  vertical  and  parallel 
to  that  of  the  astragalus  instead  of  being  at  right  angles  to  it. 

The  cuboid  bone  is  displaced  inward,  exposing  two-thirds  or  more  of  the 
anterior  articular  facet  of  the  os  calcis.  In  its  altered  position  it  sustains  the 
greater  part  of  the  superincumbent  weight,  and  becomes  from  pressure  somewhat 
wedge-shaped  from  below  upward. 

The  cuneiform  bones  are  moved  inward  and  upward  together  with  the 
scaphoid  and  cuboid,  to  which  they  retain  their  normal  relations. 


TALIPES,  OR  CLUB-FOOT. 


803 


The  greatest  deviation  from  the  normal  occurs  in  the  metatarsal  and 
phalangeal  bones,  which  give  to  the  deformity  its  characteristic  appearance. 
These  are  placed  at  right  angles  vi^ith  the  inner  side  of 
the  leg,  or,  in  severe  cases,  are  even  inclined  backvi^ard. 
The  ligaments  and  tendons  on  the  plantar  surface  are 
contracted,  the  muscles  of  the  calf  and  sole  of  the  foot 
are  atrophied,  and  bursse  are  developed  on  the  dorsum 
and  outer  side  of  the  foot.  The  skin  becomes  callous 
from  pressure,  but  otherwise  retains  its  natural  appear- 
ance, differing  in  this  respect  from  that  in  the  paralytic 
variety.  The  deformity  in  severe  eases  is  so  great  that 
the  foot  no  longer  resembles  the  normal  member,  but 
its  appearance  suggests  the  extremity  of  an  animal; 
hence  the  popular  names  of  "devil's  hoof,"  "cow- 
foot,"  etc.  Fig.  6i6.— Talipes 

Equino-varus. 

Paralytic  Equino-varus. 

This,  the  most  common  variety  of  acquired  equino-varus,  is  produced 
by  the  healthy  muscles  predominating  over  the  paralyzed.  The  external 
appearances  are  not  so  severe  nor  so  marked  as  in  the  congenital  form.  The 
foot  is  not  rigidly  fixed.  The  dorsal  projections  and  plantar  depressions  are 
absent.  The  skin  is  purplish  and  cold,  and  the  leg  is  atrophied  and  its  outline 
obscured  by  a  thick  pad  of  fat.  The  bones  of  the  tarsus  are  also  usually  atrophied,, 
and  the  foot  and  limb  are  smaller  and  shorter  than  their  fellows.  Fatty  degen- 
eration of  the  paralyzed  muscles  commences  early,  differing- 
in  this  respect  from  the  muscular  changes  occurring  in  the 
congenital  affection.  Marked  changes  also  occur  in  the  ten- 
dons, these  being  often  but  one-half  the  size  of  those  in  the  op- 
posite leg. 


Talipes  Equino-valgus. 

This  deformity  is  characterized  by  an  elevation  of  the 
heel,  associated  with  an  eversion  of  the  anterior  portion  of  the 
foot,  combining  the  conditions  present  in  the  two  simple  va- 
rieties— equinus  and   valgus. 
It  may  be  either  congenital  or  acquired,  the  latter  variety  being  much  the 
more  common.     As  an  acquired  affection  it  includes  many  of  the  severer  grades 


Fig.  617. — Taiipes 
Equino-valgus. 


804 


ORTHOPEDIC  SURGERY 


of  valgus,  so  that  it  would  seem  advisable  in  the  nomenclature  of  club-foot 
either  to  do  away  with  equino-valgus  as  a  separate  variety,  or  to  add  to  its 
importance  by  classifying  under  this  term  a  large  number  of  severe  deformi- 
ties described  hitherto  as  simple  valgus.  The  external 
appearances,  symptoms,  and  morbid  anatomy  have  already 
been  described  under  the  two  simple  forms,  and  need  not 
here  be  repeated. 

The  diagnosis  depends  upon  the  association  of  the 
two  simple  forms,  and  the  prognosis  will  be  much  influ- 
enced by  the  amount  of  equinus  present. 


Fig.      6i8.  —  Talipes 
Calcaneo-varus. 


Talipes  Calcaneo-varus. 

In  this  variety  the  heel  is  without  elevation  or  is  even 

depressed,  and  the  inner  margin  of  the  foot  is  raised,  the 

sole  contracted,  with  the  dorsum  prominent  toward  the  outer  side.     It  occurs 

as  a  congenital  affection,  but  as  an  acquired  deformity  from  paralysis  or  spasm 

it  is  exceedingly  rare,  and  many  authorities  have  doubted  its  existence. 

As  a  congenital  affection  it  results  from  a  preponderance  of  action  of  the 
tibialis  anticus,  tibialis  posticus,  and  contraction  of  plantar  fascia.  The  degree 
of  deformity  is  usually  slight,  and  always  unilateral.  The  external  appearance, 
morbid  anatomy,  and  symptoms  are  a  combination  of  the  two  simple  forms 
already  described.  A  deformity  resembling  the  one  under  consideration  some- 
times results  from  a  partial  correction  of  equino-varus,  from  omission  to  remedy 
adduction  and  plantar  contraction,  after  improper  section 
of  the  tendo  AchUlis.  For  this  reason  the  modern  method 
of  first  correcting  the  varus  should  always  be  adopted. 
The  prognosis  in  the  congenital  variety  is  good. 


Talipes  Calcaneo-valgus. 

This  is  characterizd  by  a  depression  of  the  heel,  asso- 
ciated with  an  elevation  and  abduction  of  the  anterior 
part  of  the  foot.  It  may  be  either  congenital  or  acquired, 
being  in  either  case  due  to  contraction  of  the  peronei  and 
extensor  longus  digitorum  muscles  combined  with  con- 
traction of  the  anterior  tibial  and  extensor  proprius  pollicis  muscles. 

Being  a  compound  variety  it  combines  all  the  peculiarities  of  these  two 
simple  forms.    As  an   acquired  affection  it  usually  results  from  paralysis  or 


Fig.  619. — Talipes  Cal- 
caneo-\'algus. 


TALIPES,  OR  CLUB-FOOT.  805 

articular  disease.  In  infantile  paralysis,  the  most  common  cause,  the  foot  is 
abducted  by  the  stronger  action  of  the  external  extensors  of  the  toes  and  the 
peroneus  brevis.  This,  as  pointed  out  under  valgus,  is  increased  by  the  growth 
of  the  limb,  the  foot  remaining  in  its  deformed  position.  The  diagnosis  is 
easy,  and  the  prognosis  in  the  congenital  cases  is  excellent;  in  the  acquired 
cases  it  will  depend  upon  the  amount  of  paralysis  present,  and  will  be  much 
improved  by  operative  and  mechanical  measures. 


Other  Forms  of  Club-foot. 
Pes  Cavus. 

Synonyms. — English,  Hollow-foot;  Talipes  arcuatus;    Talipes  plantaris. 
German,  Hohlfuss.     French,   Pied    Creux;     Pied-bot 
Talus.     Italian,  Piede  de  cavo.     Spanish,  Pie  cavo. 

This  consists  of  an  elevation  of  the  arch  and  an 
excavation  of  the  sole  of  the  foot.  It  may  be  either 
congenital  or  acquired,  though  the  former  is  rare.  As 
an  acquired  affection  it  results  usually  from  paralysis 
of  the  superficial  calf  muscles,  the  gastrocnemii,  and 
soleus.  It  may  also  result  from  a  contracted  condi- 
tion of  the  tibialis  anticus  and  peroneus  longus  mus- 
cles, and  the  plantar  fascia.  The  dorsum  of  the  foot 
is  increased  and  prominent,  the  sole  of  the  foot  is  Fig.  620.— talipes  cavus. 
shortened,  and  in  severe  cases  the  heel  and  balls  of  the 

little  and  great  toes  only  rest  upon  the  ground  in  walking.  As  a  primary  affec- 
tion it  is  rare,  though  the  writer  has  met  a  case,  it  being  usually  associated  with 
calcaneus;  as  such  it  usually  depends  upon  contraction  of  the  plantar  fascia. 
As  a  complication  of  congenital  equino-varus,  it  sometimes  persists  after  the 
complete  correction  of  the  equinus  and  varus  by  mechanical  extension.  The 
walk  in  congenital  cases  is  not  much  affected,  but  may  become  painful  and  even 
impossible  from  callosities  and  ulcerations  the  result  of  pressure.  In  others, 
described  as  "painful  cavus,"  tarsalgia  may  result  from  over-use,  indepen- 
dently of  the  pressure  symptoms.  The  anatomic  changes,  except  in  severe  cases, 
are  not,  as  a  rule,  marked.  The  plantar  fascia  is  contracted,  the  dorsal  ligaments 
are  elongated. 

The  diagnosis  is  easy,  and  it  has  only  to  be  distinguished  from  the  com- 
pound form,  calcaneo-cavus,  where  the  balls  of  the  toes  are  elevated  above  the 


806 


ORTHOPEDIC  SURGERY. 


level  of  the  heel.  If  the  balls  of  the  toes  are  on  the  same  horizontal  plane  as 
the  heel,  the  condition  is  called  talipes  arcuatus;  but  if  they  are  below  the  level  of 
the  heel,  it  is  designated  talipes  plantaris.  The  prognosis  in  the  congenital 
cases  is  excellent,  and  even  in  the  acquired  forms  the  deformity  may  usually  be 
much  relieved  by  appropriate  measures. 


Pes  Planus, 

Synonyms. — English,  Splay-foot;  Spurious  Valgus.  German,  Plattfuss. 
French,  Pied-plat.     J/a/m«,Piede  spianato.     Spanish,  Pie  piano. 

Splay-foot,  the   direct  opposite   of   pes   cavus,   consists  essentially  of    a 
flattening  of  the  plantar  arch  without  abduction  of  the  anterior  part  of  the 
sole.     The  latter  element  differentiates  it  from  talipes 
valgus. 

It  may  be  either  congenital  or  acquired.  It  is 
hereditary  in,  and  characteristic  of,  certain  races,  par- 
ticularly the  Jews  and  negroes. 

The  anatomic  changes  consist  in  relaxation  of  the 
ligaments  which  support  the  plantar  arch,  allowing  the 
tarsal  -bones  to  rest  upon  the  ground. 

The  entire  sole  is  applied  to  the  ground  in  walking, 
and  progression  loses  its  normal  elasticity.  Tarsalgia 
from  abnormal  pressure  is  a  frequent  symptom.  It 
never  reaches  a  degree  beyond  the  first  stage  of  valgus. 
The  normal  condition  of  the  bones  and  joints, 
especially  the  astragalo-scaphoid  joint,  serves  to  distinguish  it  from  talipes 
valgus. 

Non-deforming  Club-foot. 

Under  this  head  Shaffer  described  a  variety  of  equinus  which  hitherto  had 
escaped  the  observation  of  surgeons  and  writers  on  deformity. 

"In  non-deforming  club-foot,"  he  writes,  "all  the  conditions  found  in 
certain  forms  of  talipes  exist,  with  the  exception  of  the  exaggerated  deformity. 
That  is,  there  is  a  loss  of  normal  relation  between  the  articulation  at  the  ankle 
and  the  muscles  which  act  upon  it,  involving  also  in  many  instances  the  tarsus, 
producing  a  condition  which  prevents  flexion  at  the  ankle-joint,  and  modified 
mobility,  with  slight  deformity  at  the  tarsal,  metatarsal,  and  phalangeal  articu- 
lations.    With  this  state  of  affairs  we  find  as  a  result,  varying  with  the  conditions 


Fig.   621. — Talipes   Planus 
OR  Pes  Planus. 


TALIPES,  OR  CLUB-FOOT. 


807 


present,  actual  disability,  pain,  sometimes  very  severe,  in  various  parts  of  the 
foot,  ankle,  leg,  and  even  reflected  to  the  lumbar  region,  and  tender  and  inflamed 
articular  surfaces,  especially  at  the  junction  of  the  first  metatarsal  bone  with 
its  phalanx."  It  may  occur  at  any  age,  but  occurs  most  frequently  among 
young  and  rapidly  growing  females,  and  is  often  associated  with  true  rotary 
lateral  curvature  of  the  spine. 

The  diagnosis  is  simplified  by  a  previous  hysteric  history,  but  is  in  all  cases 
difficult  and  demands  unusual  caution. 

Non-deforming  club-foot  may  result  from  five  dift'erent  causes:  "(i)  non- 
deforming  club-foot  seen  after  poliomyelitis  anterior;  (2)  non-deforming  club- 
foot which  follows  simple  and  uncomplicated  malposition,  habit,  etc.;  (3)  non- 
deforming  club-foot  produced  by  traumatisms,  sprains,  etc. ;   (4)  non-deforming 


Fig.  622. — Non-deforming  Club-foot. 


Fig.  623. — NoN-DF.FORMiXG  Club-foot. 


club-foot  found  after  infectious  diseases  of  childhood,  especially  diphtheria 
and  scarlet  fever;  (5)  non-deforming  club-foot  due,  as  I  believe,  to  some  remote 
trophic  disturbance  and  seen  quite  frequently  coexisting  with  true  lateral  curva- 
ture." The  diagnosis  is  made  by  finding  that  the  foot  cannot  be  flexed  beyond 
a  right  angle.  The  prognosis  under  appropriate  treatment  is  excellent  and 
recovery  prompt. 


Neuromimesis  of  Club-foot. 

The  mimicry  of  club-foot,  the  so-called  hysteric  club-foot,  is  more  familiar 
to  neurologists  than  to  orthopedic  surgeons,  but  the  chapter  would  be  incom- 
plete without  some  reference  to  this  interesting  deformity.  It  occurs  most 
frequently  in  young  females  about  puberty,  and  consists  of  a  chronic  spasmodic 


808  ORTHOPEDIC  SURGERY. 

contraction  of  some  of  the  muscles  of  the  leg,  particularly  the  calf  muscles,  and 
is  usually  associated  with  some  other  hysteric  element. 

Treatment  of  Special  Varieties. 
Treatment  of  Varus. 

The  treatment  of  pes  varus  forming  a  part  of  the  congenital  variety,  equino- 
varus,  can  best  be  considered  under  the  compound  variety.  There  remains 
the  treatment  of  the  acquired  and  paralytic  varus. 
The  eversion  of  the  anterior  part  of  the  foot  in  this 
deformity  may  be  accomplished  either  by  mechanical 
measures  or  by  operative  procedures.  If  the  muscles 
are  contracted,  this  can  best  be  done  by  means  of 


^s^ajsi' 


Fig.  624. — J  UDSON's  Varus  Walk-      Fig.  625. — Brace  por  Intoeing.      Fig.  626. — Gregory  Doyle's  Ap- 
ing-brace. p.\RATUs  EOR  Residual  Varus. 


Shaffer's  varus  shoe,  the  mechanical  construction  and  action  of  which  can 
best  be  given  under  the  compound  form.  In  the  paralytic  variety  the 
elastic  traction  appliance  will  be  found  most  efi&cient.  In  some  cases 
section  of  the  plantar  fascia  and  tenotomy  of  the  tibialis  anticus  and  posticus 
will  be  necessary.  In  dividing  the  plantar  fascia  in  these  paralytic  cases 
it  is  best  to  make  but  a  moderate  division  at  first,  and  repeat  the  operation 
subsequently,  lest  the  varus  be  converted  into  a  valgus  deformity.  In  severe 
cases  it  may  be  necessary  to  resort  to  brisement  force,  but  tarsectomies  and  tar- 
sotomies are  seldom  or  never  necessary  in  these  cases.     In  this  connection  the 


TALIPES,  OR  CLUB-FOOT.  809 

treatment  of  varus,  which  remains  after  the  correction  of  compound  varieties  in 
completely  corrected  cases,  the  so-called  "residual  varus,"  may  be  referred 
to.  This  may  be  corrected  by  the  forcible  correction  of  the  deformity  under 
an  anesthetic,  with  or  without  tenotomy  as  the  case  may  require.  Mild  cases 
may  be  overcome  by  mechanical  appliances  alone,  of  which  Doyle's  apparatus 
will  be  found  the  most  efficient.  This  consists  of  a  spiral  spring  attached  to 
the  outer  part  of  the  outer  aspect  of  an  ankle  support  and  attached  at  its  upper 
extremity  to  a  pelvic  band.  By  means  of  a  key  any  amount  of  everting  force 
may  be  given  to  the  spring.  As  a  therapeutic  measure  skates  for  both  out- 
of-doors  and  parlor  use  may  be  employed  with  great  benefit. 

Treatment  of  Acquired  Valgus. 

The  treatment  of  pes  valgus  acquisitus  varies  with  its  cause  and  degree. 
Any  diathetic  tendency  must  be  corrected  by  appropriate  measures.  The 
mild  varieties  yield  readily  by  electricity  to  the  affected  muscles,  massage,  and 
removal  of  the  exciting  cause,  with  properly  fitted  metallic  sole-plate.  The 
massage  should  be  especially  applied  to  improving  the  condition  of  the  peroneal 
group  of  muscles  upon  the  outer  aspect  of  the  calf.  These  should  be  daily 
rubbed,  preferably  by  a  trained  masseur,  and  electricity  should  be  applied 
over  the  position  of  the  peroneal  muscles  and  to  the  musculo-cutaneous  branch 
of  the  external  popliteal  nerve  which  supplies  these  muscles.  Exercises  directed 
to  the  development  of  the  size  and  strength  of  these  muscles  are  also  advisable. 
Dancing,  skipping  rope,  walking  on  the  toes,  and  similar  exercises  are  valuable. 
The  following  exercises  are  to  be  recommended: 

I.  This  exercise  consists  in  standing  with  the  heels  together  and  feet  turned 
out,  then  slowly  rising  on  tiptoe,  separating  the  heels,  and  again  slowly  lowering 
them.     This  should  be  repeated  twenty  times,  night  and  morning. 

II.  This  exercise  consists  in  standing  with  the  heels  together  and  the  feet 
turned  out,  and  raising  the  front  part  of  the  right  foot  and  raising  the  inner 
side  and  gradually  approaching  the  left  part.  Repeat  twenty  times.  The 
same  exercise  is  then  performed  with  the  left  foot. 

III.  This  consists  in  sitting  with  the  heels  together  and  the  toes  turned  in. 
Both  feet  are  then  separated  in  front,  and  brought  together.    Repeat  twenty  times. 

Shoes. — Certain  requirements  should  be  met  in  shoes  to  assist  in  preventing 
the  occurrence  of  flat-foot.  The  inner  side  of  the  shoe  should  be  straight  to 
conform  to  the  normal  line  of  Meyer,  the  long  axis  of  the  great  toe  carried 
backward  should  pass  through  the  center  of  the  heel.     There  should  be  enough 


810  ORTHOPEDIC  SURGERY. 

room  in  the  front  to  allow  the  foot  to  spread  out  flat  and  to  permit  the  toes  to 
extend  individually.  The  heel  should  not  be  high.  The  upper  should  lit 
loosely  enough  to  permit  the  action  of  the  dorsum  of  the  foot  and  toes.  The 
deformities  produced  by  unsuitable  shoes  have  already  been  referred  to  in  the 
first  part  of  the  book,  and  while  a  properly  fitting  shoe  may  be  recommended  by 
the  orthopedic  surgeon,  few  persons  today  can  be  induced  to  wear  a  shoe  which 
is  properly  constructed  if  it  is  not  elegant  in  appearance.  The  principal  danger 
to  be  avoided  is  the  cramping  of  the  foot  in  front,  the  too  great  elevation  of  the 
heel,  and  the  lack  of  support  to  the  inner  side  of  the  arch. 

The  Thomas  treatment,  which  consists  in  elevating  the  inner  side  of  the 
sole  and  heel,  is  useful  in  the  early  and  acute  stages,  but  as  the  principle 
upon  which  it  is  based  is  erroneous  it  should  be  discarded  as  soon  as 
possible. 

Mechanical  Treatment. — To  support  the  arch  numerous  devices  have 
been  recommended — pads  of  leather,  felt,  rubber,  and  other  material  attached 
to  the  inner  or  outer  side  of  the  sole,  steel  bars,  springs,  etc.,  added  to  specially 
constructed  shoes,  etc.  The  writer  has  attained  the  best  results  with  the  im- 
proved plate  spring  of  Roberts.  It  consists  of  a  tempered  steel  plantar  spring, 
so  constructed  as  to  supply  an'  artificial  arch  which  prevents  further  displace- 
ment of  the  astragalus  and  scaphoid  and  supports  the  foot  as  a  whole.  It 
is  best  made  over  a  modeled  cast  of  the  foot.  A  similar  spring  without  the 
elevated  flanges  is  recommended  by  Hoffa,  who  says  one  cannot  make  the 
corrected  cast  entirely  normal  in  the  arch,  as  the  patient  cannot  stand  the 
pressure. 

This  corresponds  to  the  writer's  experience.  The  correction  should  be 
gradually  made  and  the  plate  be  changed  to  suit  the  improved  shape  of  the  foot. 
The  author  marks  on  the  cast  the  desired  shape  of  the  plate  and  corrects  the 
cast  so  as  to  apply  the  pressure  to  the  desired  point. 

The  making  of  the  casts  is  an  important  procedure.  Plaster-of-Paris 
is  mixed  with  water  to  about  the  consistency  of  thick  cream.  This  is  poured 
into  a  pasteboard  box  or  greased  tin  can  of  sufiiciently  large  size  to  hold  the  foot, 
which  after  being  greased  with  vaselin  is  placed  in  the  plaster  and  allowed  to 
remain  in  a  correct  position  without  undue  pressure  until  the  plaster  has 
hardened.  This  mold  is  then  anointed  with  vaselin,  or  a  mixture  of  sweet  oil, 
castile  soap,  and  water,  and  is  fiUed  with  soft  plaster,  an  exact  reproduction 
of  the  foot  being  obtained  in  this  manner.  The  modeling  of  this  cast 
requires  skill  and  experience,   since  a  spring  made  from  such  a  cast  would 


TALIPES,  OR  CLUB-FOOT. 


Sll 


not  fit  the  foot  comfortably  unless  it  were  modeled  to  an  exact  comaterpart  of 
the  foot. 


Fig.  627. — Author's  Spring  for  Flat-foot. 


^^^^^^^^^^^M 

"■""N.. 

t 
? 

■ 

^^^^^ 

\ 

\ 

fl 

\ 

^::>??a^---^r--'-^''3j*«5^^^-^' - 

- -^ 

^m 

Fig.  628. — Cast  of  Foot  with  Outline  of  Spring. 


Fig.  629. — Author's  Spring,  Finished  with  Le.\ther. 


In  most  cases  the  cast  must  be  modeled  to  provide  support  for  the  displaced 
head  of  the  calcaneum.     In  others  the  pronation  of  the  entire  foot  inward 


812 


ORTHOPEDIC  SURGERY. 


must  be  supported,  and  if  there  is  any  tendency  to  breaking  do-wn  of  the  anterior 
arch  support  must  be  furnished  to  the  front  part  of  the  foot.  The  plate  should 
not  extend  as  far  as  the  ball  of  the  great  toe  and  should  not  be  sloped  to  such  a 
degree  that  the  foot  is  constantly  sliding  outward.  In  most  instances  it  should 
be  made  straighter  on  the  inside,  and  the  level  of  the  heel  and  the  front  part 
of  the  plate  must  be  adjusted  to  suit  the  "tread"  of  the  foot,  and  in  some  cases 
to  suit  the  "tread"  of  the  shoe.     When  fitted  to  the  shoes,  the  springs  should 

give  comfort;  and  if  they  do  not  do  so, 
something  is  wrong  with  the  manufacture 
of  the  plates. 

Some    patients    cannot   wear   plates 

from  the  beginning,  and  in  these  cases  it 

is  necessary  to  use  pads  of  felt,  specially 

cut,   pads  of  soft  rubber,   or  small  flat 

leather  or  felt  insoles.     Hair  insoles  are  sometimes  of  service  in  producing  a  soft 

surface  for  painful  feet,  and  rubber  heels  and  rubber  soles  often  add  greatly  to 

the  comfort  of  persons  suffering  from  flat-foot. 

The  springs  may  be  made  of  tempered  steel,  German  silver,  or 
phosphor-bronze.  A  similarly  shaped  support  may  be  made  of  celluloid, 
but  the  flanges  are  omitted.  These  celluloid  supports  are  cut  from 
sheet  pyrolin,  bound  securely  to  the  corrected  cast  with  rubber  tubing, 
softened   in  boiling  water  until  they  assume  the  exact   shape   of  the  cast, 


Fig.    630. — Author's  Hard-rubber   Flat 
rooT  Spring. 


Fig.  631. — KoBEKTs     i-lat-foot  Spring,  Under 
Surface. 


Fig.   632. — Roberts'   Flat-foot   Spring,  Upper 
Sure  ace. 


when  they  are  removed,  trimmed,  and  smoothed  to  a  neat  finish  with 
proper  tools. 

In  severe  cases,  after  the  restoration  of  the  arch  by  operative  measures, 
the  spring  may  with  advantage  be  supplemented  by  an  ankle  support — two 
lateral  steel  uprights  connected  with  a  band  extending  about  the  calf,  and  an 
internal  oval  anlde-pad  over  the  mediotarsal  articulation. 

As  a  symptomatic  condition  in  osteitis  of  the  tarsus  and  ankle-joint  disease, 


TALIPES,  OR  CLUB-FOOT. 


813 


the  valgus  generally  yields  to  the  treatment  employed  for  the  primary  osseous 
or  articular  lesion. 


Fig.  633. — Ogston's  Cuneiform  Tarsectomy  for  Flat-foot. 


Fig.  634. — Same,  showing  Sutures. 


Operative  Treatment. — In   severe   cases,    before   resorting   to  extreme 
operative  measures,  all  contracted  tendons  should  be  divided.     Those  most 


814  ORTHOPEDIC  SURGERY. 

frequently  requiring  division  wUl  be  the  tendo  Achillis,  peronei,  and  extensor 
longus  digitorum,  and  they  are  best  divided  in  two  stages — the  peronei  and  ex- 
tensor longus  digitorum  first,  to  correct  the  valgus,  and  the  tendo  AchUlis  sub- 
sequently, to  correct  the  equinus,  which  in  severe  cases  is  present.  Failing 
in  the  worst  cases  to  restore  the  arch  by  such  means,  accompanied  with  manual 
force,  hrisement  force,  with  either  a  Thomas  or  Bradford  wrench,  should  be 
attempted,  or,  what  I  have  found  best,  is  the  use  of  a  Gefvert  screw-plate.  This 
consists  of  two  star-shaped  plates  attached  together  with  a  triple  screw ;  one  plate 
is  arched  to  fit  the  sole  of  the  foot.  The  appliance  is  bandaged  to  the  sole  of 
the  foot,  and  by  means  of  the  screw  any  amount  of  force  can  be  applied  to  correct 
the  deformity.  After  the  correction  a  pad  should  be  placed  against  the  arch 
of  the  foot  and  the  foot  be  fixed  in  a  position  of  extreme  varus  and  held  in  a 
plaster-of-Paris  dressing  for  two  weeks.  As  a  last  resort,  Ogston's  operation 
should  be  resorted  to,  or,  if  much  ankylosis  be  present,  a  regular  tarsectomy — 
i.  e.,  removing  a  wedge-shaped  piece  of  the  tarsus  from  the  inner  side  of  the 
tarsus  without  reference  to  the  bones  or  portions  of  bones  removed — should 
be  performed,  and  the  restoration  of  the  foot  be  completed.  A  more  satisfactory 
operation  is  that  of  Reverdin,  which  consists  in  removing  a  portion  of  the  cal- 
caneum  and  scaphoid  and  suturing  them  together,  thus  producing  an  arthro- 
desis. 

Gleich's  Operation. — The  operation  is  performed  as  follows:  An  oblique 
incision  is  made  through  the  calcaneum.  He  first  performs  a  tenotomy  of  the 
tendo  Achillis,  then  exposes  the  calcaneum  by  a  transverse  incision  similar  to 
that  of  the  Pirogoff  amputation.  He  then  saws  through  the  calcaneum 
obliquely  from  below  and  anteriorly  in  an  upward  and  posterior  direction.  He 
then  pushes  the  posterior  part  of  the  calcaneum,  which  caiTies  the  tuberosity 
downward  and  forward,  in  this  manner  reproducing  the  angle  which  the  axis 
of  the  calcaneum  forms  with  the  ground  and  which  has  been  lost  in  flat-foot. 
The  results  reported  were  perfectly  satisfactory.  The  same  result  would  be 
attained  if  a  wedge  with  the  base  do^vnward  were  cut  out  of  the  calcaneum 
and  the  posterior  part  of  the  foot  were  pushed  forward. 

These  severe  operations  should  be  resorted  to  only  when  milder  measures, 
after  due  trial,  have  failed;  for  comparative  relief  will,  in  the  great  majority 
of  cases,  be  obtained  by  the  milder  remedies  in  about  six  or  eight  weeks,  whereas 
several  months  are  required  after  any  cutting  operation  upon  the  tarsal  bones 
before  the  foot  may  with  impunity  be  freely  exercised. 


TALIPES,  OR  CLUB-FOOT.  815 

Treatment  of  Paralytic  Valgus. 

The  treatment  of  this  variety  requires  the  same  attention  to  the  employment 
of  massage,  electricity,  and  the  use  of  plantar  springs  and  other  mechanical 
appliances  as  do  the  other  forms  of  flat-foot.  The  use  of  electricity  in  these 
cases  is  particularly  serviceable,  and  the  rules  laid  down  for  its  application  under 
the  general  head  of  treatment  should  be  observed.  It  is  of  the  greatest  advantage 
in  the  infantUe  paralysis  cases  to  prevent  fatty  degeneration  of  the  muscles  and 
to  improve  the  condition  of  the  skin.  In  these  cases  marked  eversion  of  the 
foot  upon  the  leg  occurs  from  the  growth  of  the  foot,  as  pointed  out  before,  and 
the  tension  upon  the  peronei  tendons.  This  condition  may  be  overcome  in  part 
or  entirely  by  the  division  of  these  tendons  after  the  rules  previously  given  under 
the  general  head  of  tenotomy. 

After  an  operation  of  this  character  over-correction  is  not  so  essential  as  in 
ordinary  tenotomy  performed  for  contracted  tendons.  Two  weeks  should  elapse 
before  the  foot  may  with  safety  be  used,  and  at  first  only  in  moderation.  The 
greater  number  of  these  cases  also  require  a  high  sole  or  patten  to  equalize  the 
length  of  the  limbs,  since  the  paralysis  has  usually  diminished  the  growth  of 
the  limb  in  length  as  well  as  in  size.  Elastic  webbing-straps  are  often  necessary 
to  maintain  the  foot  in  a  good  position.  These  pass  from  the  inner  side  of  the 
front  part  of  the  shoe  to  the  inner  or  anterior  part  of  the  band  which  encircles 
the  leg  below  the  knee.  It  is  in  these  forms  of  club-foot  that  the  elastic  traction 
apparatus  are  most  efficient. 

Treatment  of  Equinus. 

The  treatment  of  the  congenital  equinus  forming  a  part  of  the  congenital 
equino-varus  will  be  given  under  the  compound  variety.  The  contraction  of 
the  heel  in  talipes  equinus  may  be  overcome  either  by  mechanical  or  operative 
means  according  to  the  degree  of  deformity  present.  In  the  milder  cases,  if 
the  foot  can  be  prevented  by  light  mechanical  appliances  from  turning  to  either 
side,  the  weight  of  the  body  in  walking  will  overcome  the  deformity  in  many 
instances.  A  very  useful  apparatus  is  Shaffer's  appliance  for  correcting  equinus. 
This  consists  of  two  steel  uprights  extending  from  the  upper  part  of  the  tibia 
to  the  ankle-joint,  and  attached  to  it  a  heel-cup  and  sole  to  hold  the  foot,  the  heel 
being  held  in  its  place  by  means  of  a  strap  of  webbing,  a  bandage,  or  similar 
material  passed  over  the  instep.  The  efficiency  of  this  apparatus  has  been 
increased  by  dividing  the  sole  of  the  brace  opposite  Chopart's  joint,  this  anterior 
portion  being  worked  by  an  extension-bar  passing  beneath  the  heel-cup.     The 


816  ORTHOPEDIC  SURGERY. 

apparatus  is  applied  extended  to  an  angle  corresponding  to  the  angle  of  defor- 
mity; the  heel  is  secured  by  means  of  two  straps,  one  passing  over  the  instep, 
as  before  described,  and  the  other  passing  around  the  heel  and  forward  to  be 
attached  to  either  side  of  the  sole-plate.  By  means  of  a  key  at  the  ankle-joint 
the  foot-piece  is  flexed  upon  the  upright,  and  by  means  of  the  extension-bar 
the  anterior  portion  of  the  sole  is  thrown  forward,  the  os  calcis  is  dragged  upon 
by  the  strap  passing  over  the  heel,  and  the  tendo  Achillis  is  thus  thoroughly 
stretched.  This  stretching  is  repeated  several  times  at  each  sitting,  the  pressure 
being  not  continuous,  but  a  momentary  overstretching  followed  by  relaxation. 
By  this  means  the  tendo  Achillis  may  be  extended  until  the  deformity  is  slightly 
over-corrected,  when  the  apparatus  is  substituted  by  a  retention  shoe  with  a 
stop-joint  at  the  ankle  to  keep  the  foot  in  the  corrected  position.  By  these 
mechanical  measures  the  writer  has  corrected  a  number  of  infantile  cases  of 
severe  equinus. 

In  the  severer  grades,  in  adults  and  where  the  time  for  treatment  is  limited, 
tenotomy  of  the  tendo  Achillis  will  be  found  the  most  satisfactory  plan  of  treat- 
ment. The  operation  itself  has  already  been  given  under  the  general  subject 
of  tenotomy.  After  the  section  of  the  tendon  the  foot  should  be  placed  in  a 
slightly  over-corrected  position,  and  retained  by  means  of  a  plaster  bandage. 
Two  weeks  after  the  operation  the  foot  should  be  placed  in  a  retention  walking- 
shoe  with  a  stop-joint  at  the  ankle  to  keep  the  foot  in  the  corrected  position. 

The  after-treatment  should  be  carefully  carried  out,  and  has  already  been 
given  under  the  general  subject  of  tenotomy.  If  the  deformity  has  resulted 
from  paralysis  of  the  anterior  group  of  muscles,  in  addition  to  these  measures 
electricity  and  massage  should  be  applied  to  the  whole  leg,  and  elastic  straps 
should  be  added  from  the  anterior  portion  of  the  shoe  to  the  upper  part  of  the 
brace  to  supplement  the  paralyzed  or  weakened  muscles.  In  this  connection  the 
treatment  of  "compensatory  equinus"  deserves  notice,  since  this  usually  results 
from  an  attempt  to  equalize  the  length  of  the  shortened  limb  by  an  affected  or 
acquired  equinus.  The  simple  use  of  a  cork  patten  wiU  in  the  majority  of 
cases  overcome  the  difficulty.  If,  however,  the  foot  has  remained  in  this  position 
long  enough  for  the  bones,  tendons,  and  ligaments  to  have  become  altered,  the 
mechanical  and  operative  measures  before  referred  to  will  become  necessary. 
In  "non-deforming  club-foot,"  which  in  many  cases  is  simply  an  incomplete 
equinus,  the  stretching  of  the  tendo  Achillis  by  means  of  Shaffer's  appliance 
for  correcting  equinus  will  readily  overcome  the  difficulty.  In  many  of  these 
cases  relief  is  obtained  after  one  or  two  stretchings  of  the  contracted  tendon. 


TALIPES,  OR  CLUB-FOOT.  817 

If,  however,  these  measures  should  fail  to  bring  the  foot  into  an  over-corrected 
position,  tenotomy  should  be  resorted  to. 

Treatment  of  Calcaneus. 

As  a  congenital  affection  the  treatment  of  calcaneus  seldom  requires  more 
than  daily  manipulation  and  extension  of  the  foot  to  overcome  the  deformity. 
In  the  severest  cases  tenotomy  of  the  tibialis  anticus,  peroneus  tertius,  and 
extensor  longus  digitorum  may  be  required.  The  corrected  foot  may  then  be 
retained  by  a  simple  walking-shoe  with  a  fixed  joint  to  prevent  flexion  beyond 
a  right  angle. 

Judson  has  advocated  a  brace  of  this  kind  consisting  of  an  upright  and  foot- 
piece,  the  joint  between  the  two  so  constructed  that  the  foot-piece  falls  but 
cannot  be  raised  beyond  a  right  angle  with  the  upright.  Attached  to  the  foot 
and  leg  in  standing  and  walking,  the  foot  will  remain  at  right  angles  with 
the  leg. 

The  treatment  of  the  paralytic  cases  from  anterior  poliomyelitis  can  best 
be  accomplished  by  means  of  retention  apparatus,  with  an  elastic  strap  to  limit 
flexion  beyond  a  right  angle.  Operative  interference  in  these  cases  is  indicated 
in  the  severer  forms,  and  consists  of  shortening  of  the  tendo  Achillis,  transplan- 
tation of  the  peroneal  tendon,  and  arthrodesis. 

The  best  operation  consists  in  dividing  the  tendon  after  the  oblique  method 
of  Reeves,  or  with  the  Z-formed  incision  of  Anderson,  sliding  the  cut  ends  past 
each  other  until  the  desired  shortening  is  attained  and  stitching  them  very  firmly 
together  with  chromicized  catgut,  including  the  skin  and  tendon.  The  results 
of  this  operation  are  generally  satisfactory;  not  only  is  the  deformity  corrected 
but  the  foot  frequently  resumes  the  growth  interrupted  by  the  faulty  position. 
It  is  in  this  condition  that  transplantation  of  tendons  has  proved  efiicient.  At 
the  same  time  the  tendo  Achillis  has  been  shortened.  The  peroneus  longus 
tendon  and  a  portion  of  the  flexor  longus  digitorum  should  be  sutured  in  between 
the  cut  ends  of  the  tendo  Achillis.  In  a  case  of  marked  pes  calcaneum  Hoffa 
performed  Gleich's  flat-foot  operation  in  a  reversed  manner,  cutting  the  tuber- 
osity of  the  calcaneum  through  obliquely  and  pushing  it  backward  and  upward, 
at  the  same  time  excising  a  piece  of  the  tendo  Achillis.     The  result  was  excellent. 

Arthrodesis  is  also  valuable  and  Whitman*  has  devised  an  operation  which 
combines  astragalectomy,  tendon  transplantation,  and  arthrodesis,  and  which 

*  "Am.  Jour.  Med.  Sciences,"  Nov.,  igoi. 


818  ORTHOPEDIC  SURGERY 

is  invaluable  in  inveterate  or  complicated  cases.  The  astragalus  is  removed  in 
the  usual  manner  except  that  the  peroneal  tendons  are  divided.  The  articular 
surfaces  of  bone  are  denuded  and  the  peronei  tendons,  if  active,  are  attached 
through  a  hole  into  the  os  calcis  just  below  the  insertion  of  the  tendo  Achillis. 
The  foot  is  displaced  forward,  drainage  is  not  provided,  and  the  corrected  posi- 
tion is  maintained  by  means  of  a  plaster  cast.  When  the  peroneal  tendons 
are  displaced  forward  from  behind  the  external  malleolus,  this  tendency  may 
be  corrected  by  a  bandage  or  brace,  or  if  severe  it  >  should  be  lengthened  and 
sutured  into  the  groove  from  which  it  has  slipped. 

Treatment  of  Cavus. 

The  treatment  of  the  milder  forms  may  be  accomplished  by  extension  with 
an  equinus  shoe,  particularly  the  pattern  of  Roberts,  by  which  powerful  stretch- 
ing force  can  be  applied  to  the  plantar  fascia.  The  severe  forms  will  demand 
aponeurotomy  of  the  plantar  fascia,  and  the  division  should  at  first  be  moderate 
and  repeated  lest  valgus  result.  The  after-treatment  will  consist  in  the  use  of 
an  extension  night  brace  to  prevent  relapse. 

Treatment  of  Planus. 

The  plan  of  treatment  advised  for  the  milder  forms  of  valgus  acquisitus 
or  flat-foot  may  with  advantage  be  employed  in  the  correction  of  pes  planus. 
Friction,  massage,  and  electricity  to  the  peroneal  muscles,  and  exercises  calcu- 
lated to  improve  the  power  and  tension  of  these  and  the  plantar  muscles,  should 
be  employed.  In  addition  to  these  measures  a  well-fitting  plantar  spring 
should  be  used,  changing  its  height  from  time  to  time  as  the  elevation  of  the  arch 
demands.  Systematic  exercises  are  to  be  employed,  and  dancing  is  to  be  recom- 
mended for  this  affection,  particularly  in  young  growing  girls. 

Treatment  of  Neuromimesis. 

The  treatment,  as  in  other  neurommieses,  should  be  conducted  with  the  same 
care  and  attention  to  detail  as  if  the  patient  had  a  genuine  deformity,  directing 
particular  attention  simultaneously  to  the  nervous  element  present,  and  to 
the  improvement  of  the  general  morale  of  the  individual.  Tenotomy  is  seldom 
required;  but  after  other  means  have  failed  it  may  become  necessary,  and 
may  be  undertaken  with  great  confidence. 


TALIPES,  OR  CLUB-FOOT.  819 

Treatment  of  Equino-varus. 

The  treatment  of  this  variety  of  club-foot  can  best  be  considered  under 
two  heads — the  treatment  of  the  congenital  variety  and  that  of  the  acquired 
form.  The  treatment  will  necessarily  vary  according  to  the  patient's  age  and 
the  degree  of  deformity  present;  but  the  process  of  rectification  is  best  divided 
into  two  stages — first  correcting  the  varus  and  afterward  correcting  the  equinus. 
The  correction  of  the  varus  deformity  will  include  manipulation,  massage  and 
electricity,  retentive  dressings,  extension  and  fixation,  and  tenotomy  combined 
with  extension  and  fixation.  In  the  severer  cases,  to  these  must  be  added 
brisenient  force,  tarsotomy,  and  tarsectomy. 

Manipulation  and  Massage, — The  mUder  cases,  if  treated  from  birth, 
will  often  yield  to  these  simple  measures  alone,  and  the  writer  can  refer  to  many 
mUd  cases  successfully  treated  in  this  manner.  It  is  essential  in  treating  cases 
in  this  manner  to  instruct  the  nurse  or  mother  personally  how  to  grasp  the  foot 
and  how  to  apply  the  force.  With  one  hand  the  heel  should  be  firmly  grasped, 
whUe  the  other  firmly  holds  the  anterior  part  of  the  chUd's  foot  in  a  correct 
position.  Here  it  should  be  held  for  a  few  moments,  and  this  should  be  repeated 
as  many  times  as  possible  through  the  day.  In  addition  to  this  correction 
the  muscles  of  the  calf  and  sole  of  the  foot  should  be  manipulated,  and  the  electric 
current  should  be  applied  to  the  affected  muscles  and  entire  limb,  according  to 
the  method  already  described. 

Retentive  Dressings. — The  addition  of  some  form  of  retentive  apparatus 
enhances  materially  the  prospect  of  a  cure.  For  this  purpose  numerous  mate- 
rials have  been  applied,  manufactured  from  tin,  leather,  pasteboard,  stiffened 
felt,  and  other  materials,  held  in  position  by  bandaging.  The  best  material, 
however,  for  this  purpose  is  the  plaster-of-Paris  bandage.  In  applying  this 
dressing  either  for  correction  or  retention  after  correction  of  the  deformity,  the 
technic  is  important.  All  the  bony  prominences  must  be  protected  by  a  pad- 
ding of  cotton,  over  which  a  flannel  roller  should  be  firmly  and  smoothly 
applied.  In  applying  this,  advantage  may  be  taken  of  the  direction  of  the  turns 
in  correcting  the  deformity.  Fixing  the  bandage  above  the  anlde  by  an  oblique 
and  circular  turn,  the  roller  should  run  diagonally  across  the  instep  to  the  ball 
of  the  great  toe,  across  the  sole  of  the  foot  to  the  little  toe,  to  the  outer  side  of 
the  leg  above  the  ankle,  making  firm  traction  before  proceeding  further,  so  as 
to  evert  and  elevate  the  outer  border  of  the  foot.  This  turn  can  then  be 
repeated  one-third  higher  up,  until  the  entire  foot  and  leg  are  covered, 
after  which  the  knee,  bent  at    a   right  angle,  and   the  thigh,  are  covered  in. 


820  ORTHOPEDIC  SURGERY. 

Another  method  of  applying  the  roller  consists  in  running  a  turn  around  the 
flexed  knee  down  the  leg,  around  the  foot  and  back  to  the  starting-point,  finally 
covering  in  this  turn  with  circular  turns. 

When  sufficient  turns  have  been  applied,  the  foot  and  limb  should  be  held 
firmly  in  the  corrected  position  while  the  plaster  is  setting,  applying  the  palm 
of  the  hand  to  the  sole  of  the  foot,  and  avoiding  undue  pressure  of  the  indi- 
vidual fingers  lest  the  indentations  in  the  soft  plaster  produce  sloughs. 

In  very  young  children  the  upper  part  of  the  dressing  may  be  protected 
by  a  coating  of  shellac  or  liquid  glass  to  prevent  the  soiling  of  the  dressing  by 
discharges. 

Extension  and  Fixation. — For  the  purpose  of  extension  and  fixation, 
one  of  the  many  modifications  of  Scarpa's  shoe  offers  the  best  mechanical 
means.  The  best,  however,  at  the  present  time  is  Taylor's  ankle  support  and 
Shaffer'^  and  Roberts'  modification  of  this.  Taylor's  appliance  consists  of  a 
flat  steel  sole-plate,  made  from  the  outline  of  the  plantar  surface  of  the  foot, 
and  a  steel  upright  on  the  inner  border  extending  at  right  angles  to  the  sole- 
plate  and  jointed  opposite  the  ankle.  The  foot  is  firmly  fixed  to  the  sole-plate 
by  straps  of  webbing;  the  foot  is  then  firmly  everted,  and  the  upright  is  then 
brought  into  position  at  the  side  of  the  leg,  and  retained  there  by  a  buckle  and 
strap.  This  appliance  can  be  readily  and  easily  constructed,  and  offers  an 
efficient  method  for  the  correction  of  the  varus.  It  has  also  been  employed 
to  correct  the  equinus,  but  for  this  purpose  the  additional  application  of  adhesive 
plaster  to  the  leg  is  necessary.  Shaffer's  appliance  for  the  correction  of  varus 
is  a  decided  improvement  over  this,  and  offers  the  best  mechanical  means  for 
correcting  this  deformity.  The  instrument  consists  of  a  sole-plate  made  from 
the  outline  of  the  foot,  and  divided  opposite  the  mediotarsal  joint  into  two 
parts,  attached  at  the  outer  border  by  a  hinge  and  manipulated  by  means  of 
a  screw.  To  this  sole-plate  is  attached  a  steel  trough,  fitted  to  the  inner  side 
of  the  leg  and  divided  obliquely  opposite  the  ankle-joint  by  an  oblique  hinge, 
the  direction  of  which  is  such  as  to  allow  pressure,  exerted  by  means  of  a  screw, 
to  operate  upon  the  varus  deformity.  The  mechanism  of  the  divided  portion 
of  the  sole-plate  has  been  improved  by  Roberts  by  substituting  for  the  extension- 
bar  employed  by  Shaffer  a  triple-thread  screw.  This  apparatus  is  applied  to 
the  foot  in  the  direction  of  an  angle  corresponding  to  the  angle  of  deformity. 
The  foot  is  then  forced  into  a  corrected  position,  which  does  not  produce  pain, 
and  on  several  occasions  during  the  day  the  contracted  tissues  are  momentarily 
overstretched,  held  there  for  a  few  moments,  and  then  relaxed.     In  this  manner 


TALIPES,  OR  CLUB-FOOT.  821 

little  by  little  is  daily  gained,  until  in  time  severe  deformities  are  corrected. 
The  writer  would  express  his  satisfaction  in  the  use  of  this  apparatus,  and 
report  several  severe  congenital  cases  in  private  practice  cured  by  its  use.  The 
mechanical  treatment  of  club-foot  is  not  suitable  for  public  practice. 

Tenotomy  Combined  with  Extension  and  Fixation.— A  combination 
of  tenotomy  with  extension  and  fixation  offers  one  of  the  quickest  and  best 
and  surest  methods  of  correcting  these  deformities.  The  tendons  which  will 
require  division  to  correct  the  varus  are  the  tibialis  anticus,  tibialis  posticus, 
and  plantar  fascia,  and  in  some  cases  the  division  of  astragalo-scaphoid  and 
calcaneo-cuboid  ligaments.  The  part  should  at  once  be  strongly  manipulated 
until  the  over-corrected  position  remains  with  the  application  of  but  little  force. 
It  is  then  retained  in  this  over-corrected  position  by  means  of  a  well-applied 
plaster-of-Paris  bandage,  or  by  means  of  other  retentive  apparatus. 

The  severer  forms  will  require,  in  addition  to  these  measures,  the  use  of 
powerful  correcting  force  and  some  of  the  cutting  operations  upon  the  tarsus. 

Brisement  force  should  be  applied  by  one  of  the  wrenches  or  apparatus 
already  described  in  Part  I,  in  such  a  manner  as  to  force  the  foot  into  a  varus 
position. 

Tarsectomy  and  tarsotomy  are  necessary  only  in  the  severest  forms  of 
club-foot,  and  since  they  expose  the  patient  to  considerable  risk,  their  field 
of  application  should  be  limited.  The  operation  which  would  be  called  for 
in  these  cases  would  be  one  of  the  two  operations  before  given  under  the  general 
head  of  tarsectomy  and  tarsotomy,  selecting  the  proper  operation  according  to 
the  severity  of  the  individual  case.  If  the  over-correction  has  been  thoroughly 
accomplished,  the  danger  of  relapse  wUl  be  greatly  diminished,  but  in  all  cases 
it  is  necessary  to  carry  out  the  after-treatment  strictly;  and  in  the  majority 
of  cases  a  retention  walking-shoe  is  advisable  for  at  least  one  year. 

Treatment  of  Equinus. 

The  second  division  of  the  treatment  of  equino-varus,  the  correction  of 
the  equinus,  will  require  resort  to  all  the  measures  before  given  except  the 
brisement  force.  In  the  milder  cases  strong  flexion  of  the  foot  upon  the  leg, 
many  times  repeated,  will  in  many  instances  overcome  the  deformity.  In  this, 
as  in  other  deformities,  what  has  been  gained  by  these  manual  means  may 
be  retained  by  the  use  of  fixation  apparatus  of  different  varieties.  In  the  severer 
cases  tenotomy  of  the  tendo  AchUlis,  combmed  with  extension  and  fixation, 


822  ORTHOPEDIC  SURGERY. 

should  be  resorted  to.     The  technic  of  this  has  already  been  given  under  the 
treatment  of  equinus  proper. 

Treatment  of  Acquired  Equine- varus. 

Treatment  of  acquired  equino-varus  will  require,  in  addition  to  the  measures 
already  given,  a  more  frequent  resort  to  rubber  muscles  to  supplement  the 
action  of  the  weakened  or  paralyzed  muscles.  Electricity  wUl  be  valuable  in 
the  paralytic  forms,  and  in  the  severe  grades  astragalectomy  has  been  resorted 
to  with  success.  Transplantation  of  the  whole  or  part  of  the  tibialis  anticus 
tendon  to  the  outer  side  of  the  foot  after  Lange's  method,  with  perhaps  arthro- 
desis of  the  astragalo-scaphoid  articulation  in  a  corrected  position,  will  be  found 
of  service. 

Treatment  of  Equino-valgus. 

The  treatment  of  this  compound  variety  will  include  the  treatment  pre- 
scribed for  the  two  forms  of  which  it  is  a  compound.  In  the  congenital  forms 
and  in  the  severer  grades  tenotomy  will  become  necessary. 

Treatment  of  Calcaneo-varus  and  Valgus. 

The  treatment  of  these  compound  varieties  has  already  been  given  in 
sufficient  detail  in  the  individual  forms  of  which  these  are  the  compounds. 
Muscle  transplantations,  arthrodesis,  and  tendon-shortening  are  valuable  meas- 
ures in  the  severe  forms.  In  the  paralytic  forms  this  will  consist  of  trans- 
plantation of  the  tendons  of  the  extensor  longus  hallucis  into  the  scaphoid  by 
the  periosteal  method  of  Lange,  which  will  be  found  to  be  a  valuable 
procedure,  especially  if  combined  with  arthrodesis  of  the  astragalo-scaphoid 
articulation. 


CHAPTER  XXVIII. 

OTHER  AFFECTIONS  OF  THE  FEET. 

Metatarsalgia. — Attention  was  first  called  to  this  painful  affection  of  the 
feet  a  quarter  of  a  century  ago  by  Thomas  G.  Morton,  from  whom  it  is  some- 
times called  "Morton's  toe."  Attention  was  directed  to  the  painful  affection 
caused  by  pressure  upon  the  fourth  plantar  digital  nerves,  but  since  that  time 
the  term  has  been  extended  to  include  pressure  upon  other  nerves.     It  has 


Fig.  635. — Skiagraph  showing  Metatarsalgia  from  Severe  Distortion  of  Toes. 

since  been  thoroughly  described  by  T.  S.  K.  Morton.  The  disease  has  not 
been  observed  until  after  adolescence,  and  women  appear  to  be  more  predis- 
posed to  it  than  men.  The  exciting  cause  is  usually  excessive  or  unusual  exer- 
cise on  the  foot  while  wearmg  narrow,  tight,  or  new  shoes,  or  from  changing 
from  a  firm-soled  shoe  to  one  permitting  greater  motion.     The  pressure  pro- 

823 


824 


ORTHOPEDIC  SURGERY 


duces  a  neuralgic  condition  which  may  become  neuritis.  The  foot  is  blue 
and  cold,  and  has  a  tendency  to  sweat  profusely.  The  pain  is  acute,  and  the 
"imperative  necessity  of  removing  the  shoe  regardless  of  surroundings  when 
a  paroxysm  comes  on"  is  regarded  by  Morton  as  a  pathognomonic  symptom 
of  the  disease.  Upon  examination  a  tender  point  may  be  detected  by  gentle 
pressure  with  the  finger  between  the  fourth  and  fifth  metatarsal  bones.  The 
anatomic  relations  of  the  fourth  metatarsal  joint  are  such  that  pressure  is  most 
readily  caused  at  this  point.     A  hook-like  exostosis  is  often  found  projecting 


Fig.    636. — Skiagraph   showing  Metataksalgia  from  Disease   of  Fourth  Metatarso-phalangeal 

Joint. 


downward  from  the  fourth  metatarsal  bone.  The  pressure  theory  has  been 
doubted  by  some,  and  Halstead  has  disputed  the  relationship  of  the  nerves 
to  the  heads  of  the  metatarsal  bones.  The  French  school  refers  this  condition 
to  inflammatory  lesions,  fractures,  callosities,  etc.  Many  orthopedic  surgeons 
attribute  the  condition  to  breaking-down  of  the  anterior  arch  of  the  foot.  I 
am  convinced  from  the  examination  of  a  large  number  of  cases  that  the  enlarge- 
ment and  pressure  of  the  fourth  metatarsal  bone  is  responsible  for  the  pain 
in  many  of  these  cases.  In  others  it  is  due  to  fracture  of  the  tarsal,  or  par- 
ticularly the  base  of  the  fifth  metatarsal  bone.   Metatarsalgia  is  frequently  met 


OTHER  AFFECTIONS  OF  THE  FEET. 


825 


in  the  distal  extremities  of  tlie  other  metatarsal  bones,  from  a  breaking-down 
of  the  anterotransverse  arch.  Comparatively  few  persons  suffer  any  incon- 
venience from  this  deformity;  but  in  a  limited  number  of  cases  distressing 
symptoms  develop,  such  as  irregular  attacks  of  pain,  accompanied  by  the  forma- 
tion of  a  painful  cahus  in  the  middle  of  the  ball.  This  affection  is  simpler, 
more  amenable  to  treatment  than,  and  should  not  be  confounded  with, 
the  condition  described  by  Morton.  A  glass  table  with  an  inclined  mirror 
beneath  it  is  valuable  in  ascertaining  exactly  where  the  pressure  falls.  A  skia- 
graph is  of  some  importance  in  determining 
the  condition  of  the  metatarsal  bone.  If  the 
bone  is  not  greatly  deformed,  the  disease  may 
frequently  be  cured  without  resort  to  oper- 
ation. But  if  the  bone  is  enlarged,  the  oper- 
ation becomes  necessary. 

The  treatment  of  this  affection  consists 
in  the  application  of  a  narrow  flannel  ban- 
dage about  the  ball  of  the  foot,  and  the  use 
of  proper  shoes,  the  principle  of  which  in- 
cludes a  broad  rigid  sole.  Special  shoes  are 
sometimes  made  for  these  patients.  They  are 
made  with  cavities  in  the  sole  and  with  filled- 
up  irregularities  to  better  adapt  it  to  the  de- 
formity of  the  foot.  If  the  pain  be  due  to  a 
breaking-down  of  the  anterotransverse  arch, 
a  small  felt  pad,  so  applied  as  to  restore  the 
arch,  and  secured  by  strips  of  adhesive  plaster 
and  a  gauze  roller  bandage,  would  relieve  the 
symptom.  Insoles  of  metal,  or  preferably  of 
leather,  with  an  oval  elevated  pad  under  the 

anterior  arch  will  be  found  curative  in  mild  cases.  The  separation  of  the  toes, 
and  particularly  the  fourth,  from  the  others  by  means  of  cotton  or  by  \\Tapping 
the  toes  with  adhesive  plaster  will  sometimes  relieve.  Persons  of  rheumatic  or 
gouty  diathesis  require  medical  treatment. 

Operative  treatment:  In  severe  cases  where  there  is  enlargement  of  the 
articulation  no  treatment  except  excision  of  the  metatarso-phalangeal  articula- 
tion will  be  curative.  In  most  cases  it  is  best  to  amputate  the  toe  also,  as 
there  is  no  particular  advantage  in  leaving  this  member,  and  the  wound  heals 


Fig.  637. — Skiagraph  showing  Dislo- 
cation OF  Fifth  ,Metatakso-pha- 

LANGEAL   JOINT. 


826 


ORTHOPEDIC  SURGERY 


more  quickly.  The  nerve  may  be  examined  at  the  time  of  operation,  but  re- 
moval of  a  piece  of  the  nerve  is  not  recommended  for  fear  of  progressive  neuritis. 
Pronation. — The  condition  spoken  of  as  "pronated  foot"  by  Lovett, 
Dane,  and  others  frequently  gives  rise  to  pain.  This  condition  consists  in  a 
rolling  in  of  the  inner  side  of  the  foot  from  the  superincumbent  weight.  The 
fault  lies  with  the  ankle  rather  than  with  the  arch.  The  first  symptom  is  a 
weariness  and  discomfort  upon  long  standing,  followed  later  by  pain,  with  a 
flushed  and  hot  stinging  sensation  in  the  skin  associated  with  sensitive  spots. 


Fig.  638. — Skiagraph  showing  Crowding  of  Fourth  Metatarsal  Bone,  Left  Foot,  from  Fracture 
OF  Base  of  Fifth  Metatarsal. 


The  pain  sometimes  radiates  to  the  leg  and  thigh;  and  the  patient  sooner  or 
later  loses  elasticity  of  gait  and  assumes  a  clumsy  walk,  with  the  feet  everted. 
This  affection  is  usually  due  to  the  use  of  improper  shoes.  It  may  or  may 
not  be  associated  with  flat-foot. 

The  treatment  for  this  affection  is  the  same  as  for  flat-foot,  in  addition 
to  which  greater  stress  should  be  laid  upon  the  development  of  the  weakened 
muscles. 

Sprains.— Sprains  of  the  foot,  and  particularly  of  the  ankle-joint,  fre- 
quently give  rise  to  pain  long  after  the  acute  symptoms  have  disappeared.   This 


OTHER  AFFECTIONS  OF  THE  FEET.  827 

is  most  frequently  the  case  after  Pott's  fracture  of  the  lower  third  of  the  fibula, 
which  is  always  associated  with  rupture  of  the  internal  lateral  ligament.  This 
gives  rise  to  a  flat  or  pronated  foot.  Sprains  produced  by  a  crushing  force  not 
infrequently  lead  to  flat-foot. 

Viewing  sprains  and  sprain  fractures  from  the  standpoint  of  the  orthopedic 
surgeon,  surgeons  should  attempt  to  restore  or  maintain  the  plantar  arch  during 
convalescence  from  these  injuries.     Late  ecchymoses  should  not  be  disregarded 


Kio.  639. — Skiagraph   showing   Metatarsalgia  from   Crowding   of   Fourth   Metatarsal,  before 

Operation. 


as  indicating  sprain  fractures  of  the  tarsal  bones,  and  the  plantar  arch  should 
be  restored  as  soon  as  possible  after  the  injury. 

The  treatment  of  these  sprains  consists  in  the  restoration  of  the  arch 
and  the  treatment  of  flat-foot  as  already  described,  in  addition  to  which  great 
benefit  may  be  derived  from  the  application  of  rubber  adhesive  strips  crossed 
over  the  anlde-joint  and  applied  in  such  a  manner  as  to  support  the  weakest 
part.  Pads  may  be  incorporated,  and  the  application  of  a  small  felt  pad  directly 
to  the  skin,  held  in  place  by  strips  of  adhesive  plaster  and  covered  with  a  well- 
fitting  muslin  bandage,  will  often  relieve.  Baking  in  a  hot-air  apparatus  and 
massage  should  not  be  neglected. 


828 


ORTHOPEDIC  SURGERY. 


Strain  of  the  tendo  Achillis  is  sometimes  observed  where  the  foot  has  been 
subjected  to  unusual  or  severe  efforts.  A  sensitive  point  will  be  found  upon 
pressure  at  the  origin  of  the  tendon  or  midway  between  its  origin  and  insertion. 
This  condition  resembles  rider's  strain.  The  treatment  consists  in  strapping  the 
part  with  embrocated  layers  of  adhesive  plaster,  with  rest,  to  be  followed  later 
by  massage  or  the  use  of  an  embrocation.  Strain  and  rupture  of  the  plantaris 
tendon  and  muscles  sometimes  occur,  a  condition  which  has  sometimes  been 
spoken  of  as  "tennis  leg."     The  pain  is  referred  to  the  back  of  the  leg  and  upper 


Fig.  640. — Same  as   Fig.  639,  after  Operation. 


part  of  the  calf  and  is  increased  upon  flexion  of  the   foot.     It  follows  strain 
at  lawn  tennis  and  may  be  relieved  by  fixing  the  foot  in  an  extended  position. 

Hammer-toe. — The  term  hammer-toe  is  used  to  describe  a  condition  of 
extension  of  the  first  phalanx,  and  flexion  of  the  others.  This  may  affect  one 
or  all  of  the  toes.  If  the  great  toe  be  affected,  the  ungual  phalanx  is  alone 
flexed.  The  condition  occurs  both  as  a  congenital  and  as  an  acquired  affection. 
The  former  case  is  usually  the  result  of  some  infantile  nervous  disease,  and 
the  acquired  variety  is  usually  the  result  of  wearing  shoes  that  are  too  short, 
as  a  result  of  traumatism,  or  as  a  sequel  of  some  nervous  disease.     In  attempting 


OTHER  AFFECTIONS  OF  THE  FEET.  829 

to  walk,  the  toes  become  more  flexed  and  painful;  and  painful  corns  are  formed 
over  the  interphalangeal  joints.  Some  writers  make  a  distinction  between  the 
hammer-toe  and  the  claw-shaped  toes  met  with  in  some  cases  of  paralytic 
club-foot,  but  this  does  not  seem  to  be  necessary.  Both  the  extensors  and  the 
flexors  are  found  to  be  simultaneously  contracted,  and  in  some  instances  the 
phalanx  fibers  of  the  lateral  ligament  of  the  toes,  together  with  the  plantar 
fascia,  are  contracted. 

The  treatment  in  mild  cases  consists  in  the  use  of  a  plantar  plate  through 
which  tapes  are  passed  in  such  a  manner  as  to  hold  the  toes  in  their  normal 
position.  This  is  fitted  into  a  shoe  broad,  square-toed,  and  with  a  low  heel. 
In  the  severe  cases  tenotomy  of  the  contracted  tendons  is  necessary,  and  the 
writer  performs  the  operation  by  making  an  open  longitudinal  incision  on  the 
plantar  surface  at  the  base  of  each  toe,  and  dividing  the  flexor  tendon  on  a 
grooved  director.  The  extensor  tendons  are  divided  by  the  subcutaneous 
method.  If  the  fibers  of  the  lateral  ligaments  or  the  plantar  fascia  are  con- 
tracted, these  should  be  divided.  In  rare  instances  amputation  of  the  toe  or 
toes  is  necessary. 

Claw-foot. — A  condition  similar  to  claw-hand  is  met  in  the  foot,  con- 
sisting of  a  contraction  of  all  the  toes,  similar  to  that  in  hammer-toe.  It  is 
usually  due  to  some  lesion  of  the  cord,  and  is  sometimes  associated  with  con- 
tracted foot.  Palliative  measures  are  of  little  value,  and  the  best  treatment 
consists  in  dividing  both  the  flexor  and  extensor  tendons  on  the  plantar  and 
dorsal  surfaces  of  the  foot.  The  extensors  are  best  divided  by  subcutaneous 
section,  but  the  flexors  can  be  properly  divided  only  by  an  open  incision  directly 
over  the  line  of  the  flexor  tendons  beneath  the  toes.  The  tendons  are  lifted 
up  on  a  grooved  director  and  divided  in  sight.  The  incision  should  be  sutured 
and  the  toes  should  be  fixed  in  full  extension  with  well-padded  wooden  splints 
on  the  dorsal  and  plantar  surfaces,  the  whole  being  encased  in  a  plaster-of- 
Paris  cast. 

Displacement  of  the  Toes. — The  small  toes  are  sometimes  displaced 
by  being  crowded  together  as  the  result  of  paralysis  or  the  use  of  improperly 
fitting  boots.  One  or  more  toes  may  be  crowded  down  or  up  in  such  a  manner 
as  to  make  them  painful  and  inflamed. 

The  treatment  consists  in  maintaining  the  toe  in  the  proper  position  by 
means  of  adhesive  plaster,  a  roller  bandage,  or  splints,  and  in  severe  cases 
amputation  is  sometimes  necessary. 

Individual  toes  will  sometimes  be  found  displaced  in  extension,  m  which 


830 


ORTHOPEDIC  SURGERY. 


position  they  are  held  by  the  contracted  tendon.  The  treatment  of  this  con- 
dition consists  in  dividing  the  tendon  subcutaneously  and  fixing  it  with  a  padded 
splint  in  a  flexed  position  for  two  weeks. 

Lateral  Deviations  of  the  Toes. — These  include  hallux  valgus,  hallux 
varus,  hallux  rigidus,  and  hallux  metatarsus.  The  deformities  of  the  toes 
which  are  included  under  the  titles  of  hallux  valgus,  hallux  varus,  and  hallux 

rigidus  are  very  rarely  congeni- 
tal, being  usually  acquired  from 
mechanical  causes  or  as  the  result 
of  traumatism  or  disease  of  the 
bones  and  joints,  gout,  rheumatism, 
paralysis,  and  burns  and  scars. 

Hallux  Valgus. — In  hallux 
valgus  the  great  toe  is  drawn  out- 
ward, and  much  pain  is  experienced 
in  walking,  usually  at  the  metatarso- 
phalangeal articulation.  Cramps 
are  sometimes  experienced  in  the 
foot,  especially  at  night.  The  toes 
sweat  freely,  and  corns  and  bimions 
add  greatly  to  the  discomfort.  The 
deformity  is  usually  due  to  improp- 
erly fitting  shoes,  the  great  toe  being 
forced  outward  by  the  shortness  of 
the  shoes. 

Fig.  641.— Reverdin  Operation  por  Hallux  Valgus,  The  treatment  COnsistS,  in  mild 

SHOWING  Lines  OF  Section  (Berger  and  Banzet).  .        .  .  , 

a,  b,  c,  Cuneiform  section;  d,  e,  section  of  inner  side  of        CaseS,    m   the   USe   of   an    apparatus 

SVharr^.'^''^''  ^'''  '''"'"^  ^°''^°"'  ^' ''"''''      ^^i^^^  ^'^  prevent  the  deviation  of 

the  great  toe,  protect  it  from  press- 
ure, and  prevent  injury  of  the  nail.  In  severe  cases  an  operation  is  necessary 
to  restore  the  toe  to  its  proper  position.  This  consists  in  an  excision  of  the 
metatarso-phalangeal  joint  or  osteotomy  of  the  metatarsal  bone,  and  in  rare 
cases  amputation  of  the  toe. 

Three  operations  have  been  devised  for  the  relief  of  this  condition.  Wilson 
has  recommended  the  removal  of  a  piece  of  bone  from  the  inner  surface  of 
the  head  of  the  metatarsal  bone.  The  operation  of  Reverdin  consists  in  the 
removal  with  a  pair  of  heavy  bone  forceps  of  the  proximal  end  of  the  first  pha- 


OTHER  AFFECTIONS  OF  THE  FEET. 


831 


lanx,  together  with  the  removal  of  a  cuneiform  section  with  the  base  outward 
of  the  first  metatarsal  bone  just  back  of  its  head.  The  operation  is  well  shown 
in  the  illustrations  (Figs.  641,  643).  Another  operation  which  may  be  recom- 
mended is  that  by  Keller,*  which  he  describes  as  follows: 

"A  longitudinal  incision,  two  inches  in  length,  is  made  along  the  inner 
side  of  the  foot,  exposing  the  first  metatarso-phalangeal  articulation.  The  skin 
and  tissues  over  the  head  of  the  metatarsal  bone  are  retracted;  the  joint  is 
then  opened  and  opposing  articular  ends  are  separated;   the  periosteal  covering 


£i.. 


Fig.  642. — Same,   showing  Technique  (Berger  and 

Banzet). 

Ek,  Inner  side  of  head  of  metatarsal  removed;   Ci,  C2, 

removal  of  cuneiform  section  with  cutting  forceps. 


Fig.  643. — Same,  showing  Operation 

Completed. 

Ex,  Surface  from  which  section  has  been 

removed. 


over  the  lateral  enlargement  and  the  adjoining  part  of  bone  are  pushed  back; 
and  the  exostosis,  with  about  one-eighth  of  an  inch  of  the  bone,  is  removed 
by  a  rongeur  forceps  or,  preferably,  with  a  small  saw.  The  tendon  of  the 
flexor  longus  hallucis  is  freed  by  blunt  dissection,  from  the  under  surface  of 
the  base  of  the  first  phalanx,  sufficiently  to  pass  a  Gigli  saw  around  the  bone; 
the  periosteum  is  pushed  back,  disarticulation  accomplished,  and  the  articular 
head  of  the  fiirst  phalanx  is  removed.  Particular  care  should  be  taken  through- 
out the  operation  to  protect  the  periosteum  from  needless  destruction,  and  an 


'  N.  Y.  Med.  Jour.,"  1904,  vol.  So,  p.  741. 


832  ORTHOPEDIC  SURGERY. 

effort  should  be  made  to  preserve  enough  of  it  to  cover  the  exposed  surface 
of  the  bone. 

"A  small  gauze  drain  is  inserted  betvi^een  the  head  of  the  metatarsal  bone 
and  the  sawed  end  of  the  phalanx  (this  drain  is  removed  after  forty-eight  hours). 
The  wound  is  carefully  sutured;  the  toe  being  maintained  at  normal  extension 
by  a  narrow  internal  lateral  splint.     Passive  motion  is  begun  on  the  fifth  day." 

The  advantages  claimed  for  this  operation  are  that  the  normal  tripod 
of  the  foot  is  not  disturbed,  that  the  danger  of  ankylosis  is  comparatively  slight, 
and  that  it  can  be  employed  even  when  the  normal  arch  of  the  foot  is  high. 

The  operation  which  I  prefer  is  an  osteotomy  through  the  first  metatarsal 
bone  just  posterior  to  the  head.  An  internal  padded  splint  and  a  plaster  dressing 
secure  it  in  position  for  four  weeks. 

Hallux  Varus. — The  condition  of  hallux  varus,  or  pigeon-toe,  is  exactly 
opposite  to  hallux  valgus,  in  that  the  great  toe  is  drawn  away  from  its  fellow 
and  deviates  toward  the  middle  line  of  the  body.  The  condition  may  be  due 
to  contraction  of  the  short  muscles  of  the  great  toe  as  a  result  of  spasm.  It 
is  sometimes  met  in  genu  valgum,  and  sometimes  it  is  a  result  of  equino-varus; 
occasionally  it  is  an  acquired  affection  as  a  result  of  sprinting  and  other  athletic 
sports,  the  foot  being  turned  in,  in  order  to  get  a  firmer  grasp  upon  the  ground. 
It  may  be  associated  with  macrodactyly,  or  it  may  be  bifurcated,  as  reported 
by  Clarke. 

The  treatment  is  very  unsatisfactory,  and  the  best  appliance  which  the 
\^Titer  has  met  with  is  that  of  Barton  Hopkins,  which  is  applied  to  the  heel 
of  the  shoe,  by  which  means  the  foot  is  turned  outward  at  every  step.  Me- 
chanical appliances  are  not  of  much  value,  but  an  appliance  may  be  made 
of  leather  bands  and  elastic  webbing  so  constructed  as  to  pass  over  the  outer 
side  of  the  foot,  around  the  back  of  the  calf,  to  the  inner  side  of  the  knee,  across 
the  front  of  the  thigh,  and  finally  carried  backward  to  be  attached  to  a  leather 
band  about  the  waist.  The  spiral  action  of  these  elastic  bands  will  have  a 
tendency  to  evert  the  foot.  Electricity  and  manipulation  may  be  used,  and 
in  occasional  cases  tenotomy  of  the  abductor  hallucis  may  be  performed.  In 
severe  forms  of  pigeon-toe  the  operation  of  Gibney,  consisting  of  the  removal 
of  the  tensor  vagina  femoris  muscle  by  excision,  may  be  undertaken.  When. 
bifurcated  or  supernumerary  the  inner  one  shoiild  be  amputated. 

The  condition  known  as  hallux  rigidus  consists  of  an  ankylosis  of  the 
metatarso-phalangeal  joint  of  the  great  toe.  It  is  also  known  as  "painful 
great  toe,"  "hallux  dolorosus,"  and  "hallux  flexus."     The  disease  begins  with 


OTHER  AFFECTIONS  OF  THE  FEET. 


833 


pain  and  swelling,  followed  by  deformity,  the  proximal  being  flexed  and 
the  second  phalanx  extended,  followed  by  ankylosis  and  atrophy.  This  is 
sometimes  associated  with  flat-foot,  but  is  usually  the  result  of  injury.  It 
may  be  associated  with  contracted  foot. 

The  treatment  consists  in  the  protection  of  the  joint  by  splints,  the  restora- 
tion of  the  arch  of  the  foot,  and  local  applications  of  lead-water  and  laudanum 
or  iodin,  mercury,  and  belladonna  ointment,  to  allay  the  inflammation.  In 
severe  cases  excision  of  the  joint  is  required  to  correct  the  deformity. 

Hallux  Metatarsus. — This 
affection,  which  is  also  known  as 
"congenital  hallux  varus,"  con- 
sists of  a  deviation  of  all  the  toes 
and  metatarsal  bones  inward,  the 
contraction  of  the  great  toe  being 
most  marked.  The  appearance 
is  that  of  talipes  varus,  but  the 
skiagraph  shows  the  deformity 
to  be  a  bending  of  the  proximal 
shafts  of  the  metatarsal  bones. 
The  treatment  is  not  very  satis- 
factory, but  consists  in  tenot- 
omies and  osteotomies  of  the 
deformed  structures. 

Achillodynia. — The  name 
achillodynia  has  been  given  by 
Albert  to  a  painful  aft'ection, 
bilateral,  occurring  in  the  tendo 
Achillis.     The  pain  appears  after 

walking,  and  is  relieved  by  resting  either  in  the  sitting  or  recumbent  posi- 
tion, but  the  swelling  is  persistent.  There  is  usually  an  absence  of  a  history 
of  traumatism,  rheumatism,  or  gout,  but  in  some  instances  chronic  urethritis 
is  present.  Attention  has  since  been  called  to  the  affection  by  Schuller 
and  Rosenthal.  Raynal  and  Kirmisson  have  described  a  "peri-tendinous 
cellulitis  of  the  tendo  Achillis"  which  does  not  agree  with  the  condition  de- 
scribed, nor  does  it  agree  with  the  description  by  Pitha,  a  "partial  rupture 
of  the  tendo  Achillis"  and  "partial  evulsion  of  the  insertion  of  the  tendo 
Achillis,"  the  symptoms  of  which  agree  with  the  condition  here  described^ 


Fig.  64,1 . — Metatarsus  Varus  (Jones). 


834 


ORTHOPEDIC  SURGERY. 


except  that  it  is  unilateral.  Albert  suggests  that  achillodynia  is  analogous  to 
a  condition  known  as  "rider's  strain,"  which  occurs  at  the  point  of  the  attach- 
ment of  the  great  adductor  magnus.  If  this  condition  be  analogous  to  the 
one  met  in  horseback-riders,  it  should  be  more  common  in  professional  dancers, 
but  such  is  not  the  case.  AchUlod3mia  has  been  ascribed  to  the  enlargement  of 
the  s}Tiovial  sac  and  to  the  presence  of  a  neuroma  between  the  tendon  and  the 
adjacent  structures;  a  unilateral  case  of  this  kind  has  been  reported.  The 
etiolog}'  is  unkno^^^l.     Eshner  describes  the  cardinal  symptoms  of  this  affection 


Fig.  643. — Skiagraph  of  Metatarsus  Varus  (Jones).  Fig.  646. — Skiagraph  of  Met.^tarsus  \'arus  (Jones). 


as  follows:  "The  circumscribed  character  and  symmetr}^  of  involvement,  the 
thickening  above  the  heels,  the  absence  of  inflammatory  symptoms,  the  presence 
of  pain  only  after  walking,  and  the  rapid  subsidence  of  a  first  attack." 

The  treatment  of  achillod}'nia  consists  in  rest  to  the  foot  with  direct 
injections  of  a  lo  per  cent,  solution  of  iodoform-glycerin  and  the  application  of 
an  aseptic  dressing.  Inunctions  of  mercurial  ointment  have  been  used  with 
success.     If  a  neuroma  be  present,  it  should  be  excised. 

Retro-calcaneal  Bursitis.— S}Tionyms:  Achillobursitis;  Post-calcaneal 
bursitis;    Anterior  achillobursitis.     Inflammation   of   the   bursa   between   the 


OTHER  AFFECTIONS  OF  THE  FEET.       ,  835 

tendo  Achillis  and  the  tubercle  of  the  os  calcis  is  usually  the  result  of  direct 
injury  or  severe  muscular  action.  The  acute  form  usually  results  from  par- 
ticipation in  violent  exercises  v^^hich  directly  injure  the  bursa,  or  from  pressure 
from  ill-fitting  shoes.  It  may,  however,  be  secondary  to  rheumatism,  gout, 
S3rphilis,  gonorrhea,  tuberculosis,  or  influenza.  Occasionally  it  may  result  from 
septic  infection. 

The  symptoms  are  marked  local  tenderness  over  the  insertion  of  the  tendo 
Achillis.  Swelling  is  present,  and  if  the  condition  persist  there  is  considerable 
broadening  of  the  heel  with  exostosis  of  the  calcaneum.  The  x-rsiy  is  of  value 
in  showing  the  outgrowths  of  bone.  Attention  has  been  called  by  Painter  to 
the  association  of  retro-calcaneal  bursitis  and  exostosis  of  the  calcaneum.  Pain 
may  be  experienced  in  the  calf  muscles  from  the  voluntary  effort  of  the  patient 
to  arrest  motion. 

The  treatment  consists  in  putting  the  part  at'  rest  and  in  removing  the 
pressure  of  ill-fitting  shoes.  In  severe  cases  the  foot  may  be  fixed  in  a  plaster- 
of-Paris  dressing  midway  between  flexion  and  extension.  IMassage  and  hot 
air  will  be  found  of  value  and  counter-irritation  with  iodin  or  the  cautery  should 
be  employed.  The  bursa  if  greatly  enlarged  may  be  aspirated,  or  if  infected 
it  should  be  opened  and  thoroughly  curetted.  The  constitutional  condition 
which  gives  rise  to  the  local  disease  should  be  treated.  Tuberculosis  of  the 
retro-calcaneal  bursa  wUl  require  excision.  The  exostoses  which  are  present 
should  be  removed. 

Painful  Heel. — Severe  pain  accompanied  by  tenderness  is  sometimes 
experienced  in  the  center  of  the  heel  about  the  posterior  attachment  of  the 
plantar  fascia.  It  has  been  described  as  "policeman's  heel,"  but  the  writer 
has  observed  it  in  children.  The  cause  is  obscure,  but  is  in  some  cases  asso- 
ciated with  flat-foot,  or  it  occurs  as  a  result  of  traumatism,  and  particularly 
from  strain  from  sudden  efforts,  such  as  are  made  in  acrobatic  feats.  It  is 
sometimes  due  to  inflammation  of  the  bursa  beneath  the  calcaneum.  Gout 
is  a  predisposing  cause.  Occasionally  exostoses  are  met,  and  these  probably 
indicate  a  traumatic  origin  for  the  affection,  the  periosteum  having  been  torn 
off  in  some  sudden  effort. 

Treatment  wUl  depend  upon  the  cause.  If  due  to  flat-foot  this  should 
be  corrected.  If  neuroma  be  present  in  the  bursa  or  its  vicinity,  it  must  be 
excised.  Access  to  this  bursa  may  be  had  through  a  curved  flap  about  the 
heel,  which  may  be  turned  forward,  exposing  the  deep  structures,  as  Duplay 
suggests.     If    the   bursa   be   enlarged,   it   should    be   incised   and    curetted. 


836  ORTHOPEDIC  SURGERY. 

Exostoses  should  be  removed.  Palliative  treatment  consists  in  increasing  the 
depth  of  the  hollow  of  the  heel  in  the  shoe,  the  use  of  hair  insoles,  and  rubber 
heels. 

Exostoses  of  the  Tarsal  Bones. — Under  the  tide  of  pied-force  there 
has  been  described  by  the  French  military  surgeons,  Boisson  and  Chapotot,  a 
painful  condition  of  the  feet  occurring  among  soldiers  as  a  result  of  prolonged 
marches.  Pain  and  swelling  of  the  dorsum  of  the  foot,  resulting  in  disability, 
followed  by  exostoses,  particularly  of  the  second  metatarsal  bone,  are  symptoms 
of  the  affection.  The  only  condition  which  this  resembles  is  gout.  The  acute 
attacks  of  gout  met  with  over  the  instep  are  often  misleading,  and  the  severe 
erythema  which  sometimes  accompanies  cardiac  disease  should  be  promptly 
recognized.  Severe  itching  of  the  soles  of  the  feet  and  eyelids  should  direct 
attention  to  the  lithemic  condition.  Both  these  conditions  are  precipitated  by 
injurious  pressure  from  shoes  too  tight  over  the  instep. 

Exostoses  of  the  tarsal  bones  are  met  in  other  parts  of  the  foot  as  a  result 
of  strain  and  overuse.  The  prominence  of  the  first  and  second  metatarsal 
bones  which  is  met  with  in  inherited  gout  should  not  be  confounded  with  the 
exostoses  occurring  from  other  causes.  This  is  a  very  common  condition,  and 
gives  rise  to  an  exaggerated  arch,  considered  by  some  as  a  mark  of  distinction. 
The  latter  is  unaccompanied  by  pain  and  is  a  hereditary  condition.  The  exostoses 
are  best  investigated  by  means  of  a  skiagraph,  and  their  removal  is  not  always 
followed  by  relief. 

The  treatment  consists  in  baking  in  a  hot-air  apparatus,  massage,  anod}Tie 
applications,  and  rest.  The  shoes  may  be  improved  sometimes  by  increasing 
the  depth  of  the  heel,  and  by  the  use  of  rubber  soles  and  heels. 

Erythromelalgia. — Under  the  name  of  erythromelalgia  Weir  INIitchell 
has  described  a  condition  of  the  feet  characterized  by  excessive  fatigue,  at 
first  after  long  walks,  and  subsequently  after  slight  exertion,  arising  in  the 
summer.  In  one  instance  I  attributed  the  cause  to  repeated  exposure  of  the 
feet  to  severe  cold.  The  burning  pain  at  first  becomes  severe,  but  is  relieved 
by  rest,  cooling  applications,  and  elevation.  The  feet  are  red  and  swollen  upon 
the  slightest  e.xertion,  with  elevation  of  temperature,  which  symptoms  rapidly 
subside  upon  resting.  The  condition  is  due  to  vasomotor  paral)^sis  of  the 
extremities,  and  is  most  common  in  males  over  thirty-five.  INIales  are  more  fre- 
quently affected  than  females.  Thus,  in  27  cases  collected  by  ^^'eir  jNIitchell, 
only  2  were  in  females.     I  have  seen  the  severest  cases  in  females. 

The  treatment  consists  of  rest,  the  application  of  cold,  resort  to  a  cold 


OTHER  AFFECTIONS  OF  THE  FEET.  837 

climate,  and  nerve-section  in  suitable  cases.  A  case  of  nerve-section  followed 
by  recovery  is  recorded  by  Weir  Mitchell. 

Pododynia. — Under  the  title  of  pododynia  Gross  has  described  a  painful 
condition  occurring  in  tailors.  Upon  assuming  the  erect  posture  pain  and 
tenderness  of  a  deep-seated  character,  increased  upon  pressure,  are  experienced. 
Pain  is  also  felt  in  walking  and  standing,  the  swelling  is  slight,  and  discoloration 
rarely  occurs.  This  disease  is  in  some  way  related  to  the  preceding  one,  but 
its  exact  cause  is  unknown.  It  is  probably  due  to  the  strain  thrown  upon 
the  insertion  of  certain  muscles  from  the  sitting  position  assumed  by  taUors. 

Plantar  neuralgia  from  a  variety  of  causes  is  not  uncommon.  It  is  tech- 
nically known  as  plantalgia.  The  most  common  cause  is  from  stretching  or 
rupture  of  the  plantar  fascia  in  pes  cavus,  and  I  have  knovra  it  to  follow  tenotomy 
of  this  fascia  and  be  accompanied  by  induration  and  sensitiveness  to  pressure. 
In  severe  cases  excision  of  the  sclerosed  tissue  may  be  required.  The  plantar 
neuralgia  present  in  flat-foot  as  the  result  of  pressure  upon  the  plantar  nerves 
by  the  displaced  bones  has  already  been  referred  to  in  its  proper  place. 

In  examinations  of  all  painful  affections  of  the  feet  the  surgeon  should 
not  overlook  the  possibility  of  their  being  due  to  gout,  to  rheumatism,  or  to 
cardiac  or  renal  disease. 


CHAPTER  XXIX. 

CONGENITAL  DISLOCATIONS  OF  THE  HIP,  KNEE,  SHOULDER, 

AND  ELBOW. 

Congenital  Dislocation  of  the  Hip. 
Congenital  dislocation  of  the  hip  is  a  displacement  of  the  head  of  the  femur, 
occurring  before  birth,  due  in  most  cases  to  arrest  of  growth  or  retarded  develop- 
ment of  the  acetabulum,  and  tending,  without  treatment,  to  remain  stationary 
or  to  grow  worse.  The  deformity,  in  the  strictest  sense,  is  not  a  dislocation, 
but  more  properly  a  misplacement,  since  there  is  an  arrest  of  development 
of  the  constituent  parts  of  the  joint,  and  some  of  the  most  important  elements 
of  a  luxation,  as  the  rupture  of  the  capsule,  are  absent.  The  designation  of 
"dysarthrosis  congenita"  and  "congenital  malposition,"  or  "congenital  mis- 
placement," would  therefore  seem  more  appropriate,  but  the  term  congenital 
dislocation  will  be  here  retained  on  account  of  its  general  acceptance. 

Frequency. 

While  in  itself  not  a  common  affection,  congenital  dislocation  of  the  hip 
is  the  most  frequent  of  all  congenital  dislocations.  Thus,  Kronlein  observed 
ninety  cases  of  this  affection  to  one  of  the  knee,  five  of  the  humerus,  and  two 
of  the  radius.  Its  relative  frequency  is  a  little  less  than  one  in  a  hundred  cases 
of  surgical  disease;  thus,  in  7900  cases  of  surgical  disease  treated  at  the  Boston 
Children's  Hospital,  39  were  cases  of  congenital  dislocation  of  the  hip.  Of 
370  cases  treated  by  Hoffa,  321  were  girls,  49  were  boys;  140  were  double  and 
230  were  single. 

DoUinger,  in  859  cases  of  deformity,  found  that  there  were  9  cases  of  this 
affection,  or  i.i  per  cent.  Chaussier,  in  23,292  newborn  children  at  the  Paris 
Maternity,  found  only  one  case,  whereas  Parise  found  congenital  dislocation  of 
the  hip  three  times  in  332  autopsies  upon  newborn  children  at  the  Hopital  des 
Enfants  Trouves. 

During  the  last  fifteen  years  120  cases  of  this  affection  have  come  under 
my  observation.  Of  these,  17  were  boys,  103  girls;  80  were  single  and  40 
double. 

S3S 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


839 


The  relative  number  of  boys  and  girls  and  the  relative  distribution  of 
the  affection  are  well  shown  in  the  following  table,  arranged  from  various 
sources : 

STATISTICS  OF  CONGENITAL  DISLOCATION  OF  THE  HIP. 


Orachmann, 77 

Pravaz,  Jr., 107 

Kronlein, S5 

Ho£fa, 370 

Lorenz, i  671 

Kirmisson, 82 

Whitman, 500 

Boston  Children's  Hospital, 24 

New  York  Orthopedic  Hospital, 20 

Milan  Polyclinic,  Bernacchi,* 1039 

Young, 120 

Prahl.t 18 


172 

17 

3 


GlELS. 

Right. 

Left. 

67 

24 

24 

96 

29 

27 

71 

22 

32 

321 

104 

126 

589 

225 

196 

73 

31 

20 

413 

135 

318 

24 

II 

7 

18 

10 

S 

867 

i°3 

36 

44, 

15 

0 

0 

29 
51 
31 

140 

245 
31 
136 

6 
5 


From  these  statistics  of  3 113  cases  of  congenital  dislocation  of  the  hip, 
456,  or  14  per  cent.,  were  in  males;  and  2657,  or  86  per  cent.,  were  in  females. 
The  females  were  affected  seven  times  more  frequently  by  the  deformity  than 
were  the  males.  The  unqualified  assertion  of  Dupuytren,  that"  females  are 
more  liable  to  malformation,  is  the  only  reason  which  has  ever  been  advanced 
to  account  for  this  preponderance.  That  this  may  be  due  to  an  anatomic 
peculiarity  would  seem  to  be  proved  by  the  conclusions  of  Heusner|  and  Marc- 
wald,  who  found  in  female  fetuses  a  disproportionate  laxity  of  the  capsule. 
It  is  also  apparent  from  these  statistics  that  single  dislocation  is  more  frequent 
than  double,  and  that  the  left  side  is  more  frequently  affected  than  the  right. 

Etiology. 

As  in  the  study  of  the  causes  of  all  congenital  affections,  there  is  in  this 
much  that  is  speculative  and  purely  theoretic.  Dislocation  of  the  hip  differs 
from  other  congenital  affections  in  that  it  is  rarely  associated  with  other  de- 
formities, the  children  being  usually  otherwise  well  formed  and  healthy.  The 
vn-iter  has,  however,  seen  an  instance  in  which  there  was  congenital  deficiency 
of  the  femur,  tibia,  and  other  parts  associated. 

The  numerous  theories  which  have  been  advanced  may  be  considered 
under  the  following  heads : 


*  Bernacchi,  "Zeits.  f.  orth.  Clin.,"  vol.  ii,  p.  273. 
t  Lovett,  "Diseases  of  Hip-Joint,"  1891,  p.  183. 
}"  Zeits.  f.  orth.  Clin.,"  1902,  Bd.  x,  H.  4. 


840 


ORTHOPEDIC  SURGERY 


1.  Theory  of  heredity. 

2.  Theory  of  mechanical  intrauterine  pressure  or  traumatism. 

3.  Theory  of  pre-natal  disease. 

4.  Theory  of  arrest  or  defect  of  development. 

I.  Heredity  exerts  a  powerful  and  important  influence  over  the  occurrence 
of  this'deformity,  and  may  explain,  as  pointed  out  by  Vallette,  the  frequency 
of  this  affection  in  certain  parts  of  France,  a  fact  also  referred  to  by  Albert, 


Fig.  647. — Unilater.vi.  Dislocviiox  of  V.if  (.Back 
View). 


Fig.  648. — Same  (Fro.mt  View). 


who  met  with  it  exceptionally  often  in  the  Tyrol.  As  an  etiologic  factor  its 
influence  can  scarcely  be  doubted.  Persons  suffering  from  this  deformity  may 
leave  several  children  similarly  afflicted,  and  individual  hereditary  cases  are 
recorded  by  almost  all  writers.  Redard  cites  an  instance  where  a  normal  parent 
gave  birth  to  three  daughters,  all  of  whom  had  double  dislocation,  and  Zwinger 
cites  a  case  where  a  mother  deformed  by  dislocation  had  three  daughters  simi- 
larly afflicted.  The  case  of  INIargaret  Cardas,  reported  by  Dupuytren,  eight 
of  whose  relatives  were  similarly  afflicted,  is  particularly  interesting. 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


841 


2.  The  theory  of  mechanical  intrauterine  pressure,  or  travunatism, 

through  deficient  liquor  amnii,  compression,  or  the  peculiar  position  of  the 
fetus  in  iitero,  or  by  a  fall  or  blow,  is  as  old  as  medicine  itself.  Hippocrates 
himself  averred  that  "infants  in  the  very  womb  may  have  their  joints  dislocated 
by  a  fah,  a  blow,  or  compression."  Cruveilhier,  Roser,  and  Lucke  have  sup- 
ported the  uterine  compression  view  due  to  deficiency  of  the  amniotic  fluid, 
strong  adduction  being  induced  in  this  manner. 

External  violence  to  the  mother  is  believed  by  some  to  account  for  occa- 


FiG.  649. — Bilateral  Dislocation  of  Kip  (Front 
View)  (Hopkins). 


Fig.  650. — Same  (Side  View). 


sional  cases.  Thus,  three  cases  were  attributed  to  a  fall  in  the  seventh  month 
of  pregnancy  by  Kleeburg,  Chatelain,  and  Zielewicz.  The  violent  muscular 
movements  of  the  fetus  itself  have  likewise  been  ascribed  as  a  cause,  and 
Chaussier  c[uotes  a  case  of  congenital  dislocation  to  the  forearm  in  support 
of  this  theory. 

The  argiunents  against  the  pressure  theory  under  the  etiology  of  congenital 
club-foot  apply  with  greatest  force  here,  since  congenital  dislocation  of  the 
hip  is  very  rarely  associated  with  other  deformity;  there  is  no  appreciable 
difference  observed  in  the  quantity  of  liquor  amnii  over  previous  births  of 


842  ORTHOPEDIC  SURGERY. 

normal  children,  and  but  few  cases  are  recorded  where  the  cause  can  be  directly 
traced  to  external  or  internal  traumatism  to  the  fetus.  J^Ioreover,  external 
violence  would  produce  fracture  in  utero  rather  than  dislocation. 

The  large  proportion  of  breech  deliveries  in  these  cases  has  been  cited 
as  corroborative  evidence  of  traumatism  as  a  cause  of  congenital  luxations. 
Adams  reports  seven  breech  presentations  in  forty-five  cases.  The  necessary 
obstetric  operations  employed  in  breech  deliveries  may  and  frequently  do, 
cause  dislocation, — the  so-called  obstetric  dislocations, — which,  if  unreduced, 
wUl  later  in  life  resemble  in  every  respect  congenital  dislocation;  but  such 
cases  should  not  be  classed  as  congenital,  but  as  traumatic.  Such  a  dislocation 
is  more  liable  to  occur  if  the  upper  rim  of  the  acetabular  cavity  be  deficient, 
but  that  it  is  possible  with  a  normal  cotyloid  cavity  is  illustrated  by  the  experi- 
ments of  Melcher,  of  Vienna,  upon  the  cadavers  of  women  who  had  died  unde- 
livered. He  found  it  possible  to  produce  dislocation  with  the  fingers  or  a  hook 
in  six  instances  in  which  the  acetabulum  was  perfectly  formed.  Phelps  reported 
a  case  of  obstetric  dislocation  of  the  hip  which  he  reduced  one  hour  after 
birth. 

From  the  experiments  of  Allis  and  others  it  would  seem  to  be  demonstrated 
that  a  certain  proportion  of  cases  are  the  result  of  traumatism.  When  dislo- 
cation of  the  hip  is  produced  by  pressure,  or  traumatism,  it  may  easUy  be  effected 
if  the  femur  is  flexed,  adducted,  and  rotated  inward ;  and  the  greater  the  degree  of 
these  angles,  the  easier  is  the  production  of  the  dislocation.  These  conditions 
are  found  to  be  present  in  the  fetus  in  the  normally  flexed  position  of  the  femur 
and  the  adduction  which  is  present,  and  it  may  be  assisted  by  the  deficiency 
of  liquor  amnii,  or  by  the  small  size  of  the  uterus  and  the  presence  of  internal 
rotation,  which  is  also  normal  in  early  fetal  life.  Internal  rotation  is  always 
associated  with  adduction;  for  example,  if  a  person  sitting  in  a  chair  adducts 
his  knees,  the  foot  is  inverted,  during  internal  rotation  of  the  femur.  When 
dislocation  occurs  in  this  way,  the  force  is  probably  applied  to  the  distal  ex- 
tremity of  the  femur,  which  is  the  best  possible  manner  in  which  to  apply  the 
leverage.  With  these  three  conditions  present,  flexion,  adduction,  and  internal 
rotation,  a  moderate  amount  of  force  gradually  applied  would  probably  produce 
the  deformity. 

The  greater  frequency  of  congenital  luxations  of  the  hip  in  girls  may  also 
be  explained  upon  mechanical  principles  from  the  fact  that,  as  stated  by  Cun- 
ningham, the  sexual  differences  of  the  pelvis  are  as  pronounced  in  the  third 
or  fourth  month  of  fetal  life  as  they  are  in  the  adult,  and  therefore  the  greater 


CONGENITAL  DISLOCATION  OF  THE  HIP.  843 

breadth  of  the  pelvis,  with  the  femur  in  the  position  described,  would  result 
in  a  larger  proportion  of  this  deformity  in  girls. 

The  traumatic  theory  does  not  explain  certain  conditions  which  are  found 
to  be  present.  The  fact  that  the  capsule  is  not  torn  may  be  accounted  for 
by  the  time  which  has  elapsed  since  the  production  of  the  deformity,  it  having 
had  time  to  repair;  or  if  the  deformity  occurred  gradually,  the  capsule  may 
have  been  stretched.  The  obtuse  angle  of  the  neck  of  the  femur  can  be 
accounted  for  by  the  pressure  of  the  femur  upon  the  ilium  after  the  dislocation 
has  occurred.  The  production  of  an  occasional  anterior  displacement  can 
also  be  accounted  for  by  this  theory,  by  forward  displacement  from  a  previous 
posterior  dislocation  during  the  delivery. 

From  a  careful  consideration  of  the  different  theories  which  have  been 
advanced  and  an  examination  of  a  number  of  specimens,  it  appears  to  the 
writer  that  a  certain  number  of  these  deformities  are  produced  by  traumatism, 
probably  50  per  cent.  Of  the  remaining,  a  certain  percentage,  perhaps  20 
or  30  per  cent.,  are  probably  due  to  arrest  of  development,  the  former  being 
entirely  amenable  to  treatment  and  the  latter  only  partially  so.  The  remaining 
percentage  can  be  accounted  for  by  the  other  theories. 

3.  The  theory  of  pre-natal  disease,  or  the  musculo-nervous  theory, 
due  to  intrauterine  lesions  identical  with  post-natal  diseases,  has  been  sup- 
ported by  a  host  of  eminent  authorities. 

(a)  According  to  some,  the  dislocation  is  spontaneous,  being  due  to  soften- 
ing and  looseness  of  the  coxo-femoral  ligaments,  to  effusion  and  fungous  synovi- 
tis, to  hydrarthrosis,  or  to  caries,  arthritis,  or  other  destructive  joint  inflam- 
mations. 

(6)  According  to  the  majority,  it  is  due  to  primary  muscular  contraction, 
which  is  to  be  regarded  as  secondary  and  consecutive  to  a  central  nervous 
lesion. 

(c)  According  to  a  few,  it  is  regarded  as  often  the  last  stage  of  a  paralysis 
and  atrophy  of  the  peri-trochanteric  muscles,  and  the  frequency  of  the  dorsal 
iliac  dislocations  over  other  forms  is  cited  as  confirmatory.  In  regard  to  this 
theory  it  may  be  remarked  that  the  analogous  deformities  from  which  this 
theory  was  derived— -club-foot,  wry-neck,  and  scoliosis— are  not  now  regarded 
as  the  result  of  primary  muscular  spasm;  central  cerebral  and  spinal  lesions 
have  not  been  demonstrated;  and  the  anatomy  of  the  hip-joint  is  such  that 
muscular  spasm,  independent  of  other  causes,  could  not  produce  dislocation. 
Moreover,  the  dislocation  is  not  always,  as  it  should  be,  upward  and  backward, 


844  ORTHOPEDIC  SURGERY. 

but  may  be  upward  and  forward,  or  downward  and  forward,  or  dowTiward 
and  backward.  Wliile  in  anencephalous  fetal  monsters  the  association  of  con- 
genital dislocation  of  the  hip,  club-foot,  and  other  deformities  is  confirmatory 
of  this  theory,  many  monstrosities  with  extensive  demonstrable  nervous  lesions 
have  no  deformity  of  the  extremities  whatever. 

4.  The  theory  of  arrest  or  defect  of  development,  or  the  osseous  theory, 
has  received  the  weight  of  modern  authority  as  rational  and  scientific.  Pro- 
posed by  Paletta,  indorsed  by  Von  Ammon  and  others,  it  has  of  late  years 
been  confirmed  and  established  upon  a  scientific  basis.  In  considering  this 
theory  it  must  be  remembered  that  the  acetabulum  is  formed  by  the  growth 
of  the  pelvic  cartilage  around  the  head  of  the  femur,  which  by  the  third  month 
is  a  deep  cup-like  cavity.  DoUinger  believed  the  cause  to  be  a  premature 
ossification  of  the  Y-cartUage  of  the  acetabulum,  while  Grawitz,  from  the  ex- 
amination of  specimens  and  numerous  and  careful  experiments,  including  micro- 
scopic examinations,  seems  to  have  demonstrated  it  to  be  due  to  arrest  of  devel- 
opment of  the  same.  The  same  lack  of  development  of  the  acetabulum  is 
observed  from  non-use  after  luxation  of  the  head  of  the  femur,  and  it  has 
been  questioned  whether  this  condition  is  primary  and  causative  or  secondary 
from  non-use.  The  observations  of  Grawitz  would  seem  to  prove  the  former. 
The  malformation  may  consist  of  the  absence  of  a  rim  to  the  acetabulum, 
with  or  without  displacement  of  the  head  of  the  femur,  as  in  two  specimens 
reported  by  Lockwood.  This  theory  makes  congenital  dislocation  of  the  hip 
analogous  with  other  deformities,  explains  its  association  with  other  malforma- 
tions, and  offers  an  explanation  for  those  cases  which  are  not  due  to  traumatism 
or  pre-natal  disease. 

The  facts  which  support  this  theory  are  that  the  capsule  is  found  to  be 
untorn  and  the  joint  is  found  to  be  undeveloped.  But  it  would  not  account 
for  the  vast  majority  of  posterior  luxations,  it  would  not  account  for  the  occa- 
sional anterior  displacements,  it  does  not  account  for  the  large  number  of  cases 
occurring  in  girls,  nor  does  it  explain  the  obtuse  angle  of  the  shaft  with  the 
head  of  the  femur. 

Pathology. 

Prior  to  1890,  when  the  open  operation  was  first  performed,  the  descriptions 
of  the  pathologic  anatomy  of  congenital  dislocation  of  the  hip  were  based  upon 
the  original  observations  of  Dupuytren,  autopsies  upon  new-born  children, 
and  a  few  authentic  specimens  in  museums.     Since  that  time  the  descriptions 


CONGENITAL  DISLOCATION  OF  THE  HIP.  845 

of  Hoffa,  Lorenz,  Schede,  and  other  operators,  together  with  the  study  of  the 
Rontgen-ray  pictures,  have  added  greatly  to  our  exact  knowledge  of  the  subject. 
The  dislocation  may  be  complete  or  incomplete;  the  incomplete  luxation 
at  birth  usually  becomes  converted  into  a  complete  pne,  as  soon  as  the  child 
begins  to  walk,  from  the  weight  of  the  body.  The  position  of  the  head  is  usually 
backward  upon  the  dorsum  of  the  ilium,  but  it  may  be  upward,  resting  above 
the  acetabulum,  or  forward,  the  head  lying  beneath  the  anterior  superior  spine 


Fig.  651. — Skiagraph  showing  Unilateral  Dislocation  of  Hip. 

of  the  ilium.  The  primary  position  in  newborn  children  is  probably  directly 
upward,  or  upward  and  slightly  backward. 

The  pathologic  changes  are  of  two  kinds — those  found  in  the  affection 
itself  and  those  produced  by  walking  upon  the  deformed  joint.  For  convenience 
of  description  the  pathologic  anatomy  is  best  considered  as  it  occurs,  in  the 
newborn,  in  children  who  have  walked,  and  in  adults. 

At  Birth. — In  autopsies  upon  newborn  children  the  acetabulum  is 
undeveloped  and  narrowed,  elongated,  less  concave  than  normal,  covered 
with  normal  hyaline  cartilage,  and  occasionally  filled  with  fat  and  connective 


846  ORTHOPEDIC  SURGERY. 

tissue.  The  acetabulum  is  seldom,  if  ever,  found  to  be  entirely  absent,  though 
the  upper  part  of  the  cartilaginous  rim  may  be  wanting;  in  which  event  the 
cavity  is  continuous  with  the  surface  of  the  ilium. 

The  head  of  the  femur  is  occasionally  irregular  and  atrophied,  but  is 
always  slightly  larger  than  the  concavity  of  the  acetabulum.  The  neck  is 
conical,  short,  and  the  angle  formed  with  the  diaphysis  is  less  obtuse. 

The  round  ligament  is  abnormally  long,  filiform  in  shape,  occasionally 
more  developed  than  normal,  and  seldom  if  ever  absent. 

The  capsule  is  thinned  and  capacious  and  the  cavity  is  distended  with 
fluid.  "When  the  head  is  reduced  by  traction,  inward  rotation,  and  extension, 
the  upper  part  of  the  capsule  becomes  wrinkled,  while  the  anterior  and  posterior 
fibers  are  tightened. 

The  muscles  about  the  joint  become  atrophied  and  retracted  by  the 
changed  relations;  the  quadratus  femoris,  obturator  extemus,  psoas,  and 
iliacus  being  particularly  influenced  by  the  displacement  upward  of  the  femur. 
Vemeuil  found  in  an  autopsy  upon  an  infant  affected  with  congenital  dislocation 
of  the  hip  of  the  left  side  that  the  muscles  of  the  affected  side  were  less  developed 
and  shorter  than  the  right,  and  Lannelongue  found  an  atrophy  of  the  entire 
dislocated  leg,  but  without  one  trace  of  degeneration. 

The  pelvis  is  compressed  laterally,  the  direction  of  the  os  pubis  is  less 
inward  than  in  the  normal  bone,  and  the  superior  and  inferior  straits  are  con- 
tracted. 

In  Children  Who  Have  Walked. — In  subjects  who  have  walked  the 
changes  are  more  marked  and  progressive. 

The  acetabulum  is  smaller,  triangular,  and  filled  with  fat  or  firm  fibrous 
tissue.  Under  the  influence  of  walking  the  head  tends  to  elongate  the  cavity. 
One  or  more  depressions  exist  where  the  head  of  the  femur  has  rested,  and 
on  the  position  of  these  new  sockets  depends  the  angle  of  the  pelvis  and  the 
amount  of  lordosis,  for  if  they  form  directly  above  the  acetabulum,  the  normal 
plane  remains  practically  unchanged;  but  if  they  are  much  behind,  the  pelvis 
is  tnted  and  severe  lordosis  results.  A  partial  rim  of  bone  sometimes  forms 
above  and  around  the  new  socket,  to  which  is  attached  the  capsular  ligament. 
The  surface  of  the  ilium  is  smooth  and  where  the  head  of  the  femur  rests  it 
is  indurated  and  eburnated. 

The  head  of  the  femur  is  small,  conical,  and  generally  flattened  at  its 
posterior  superior  segment  from  pressure  upon  the  dorsum  of  the  ilium. 

The  neck  is  shortened  or  entirely  wanting,  the  head  resting  immediately 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


847 


upon  the  diaphysis.  Generally  it  is  undeveloped  and  placed  obliquely  in  a 
position  of  anteversion,  lessening,  and  in  many  instances  increasing,  the  forward 
inclination  of  the  neck. 

The  capsule  is  relaxed,  enlarged,  and  thickened,  and  in  some  cases  is 
constricted  into  the  form  of  an  hour-glass.     The  communication  between  the 


Fig.  652. — Skiagraph  showing  Bilateral  Dislocation  of  Hips. 


two  parts  is  sometimes  obliterated  after  the  disappearance  of  the  round  ligament. 
The  capsule  is  inserted  about  the  upper  portions  of  the  old  and  new  acetabuli. 

The  ligamentum  teres  is  flattened  and  thin,  sometimes  arising  by  two 
heads,  and  in  others  being  entirely  absent.  Its  presence  prevents  adhesion 
between  the  naiTOwed  portion  of  the  capsule,  where  the  interior  portion  of 
the  capsule  rests  against  the  upper  border  of  the  acetabulum. 


848  ORTHOPEDIC  SURGERY. 

The  muscles  are  displaced  by  the  changed  relations  of  the  articulation, 
some  being  lengthened,  others  shortened.  The  obturators,  gemelli,  and  pyra- 
midalis  are  lengthened,  while  the  psoas,  iliacus,  rectus,  tensor  vaginae  femoris, 
hamstring  muscles,  and  the  adductor  group,  particularly  the  middle  and 
lower  portion  of  the  adductor  magnus,  are  shortened,  as  pointed  out  by 
Bradford.* 

In  a  recent  case  where  I  assisted  Hoffa,  at  the  University  Hospital,  Phila- 
delphia, with  a  single  open  reposition  in  a  boy  six  years  old,  the  anatomical 
parts  were  characteristic  of  the  deformity  at  this  age. 

In  Adults. — In  adult  cases  the  changes  are  all  advanced;  exostoses  fill 
the  cavity  of  the  acetabulum  and  form  an  elevated  border  above  the  new  socket. 

The  head  of  the  femur  becomes  more  displaced  and  may  rest  imme- 
diately upon  the  ilium. 

The  capsule  may  be  absorbed  by  friction  in  its  posterior  part.  Above 
it  becomes  greatly  thickened,  and  may  become  ossified  where  it  is  attached 
to  the  osteophytic  upper  portion  of  the  new  acetabulum.  The  new  cavity 
may  be  sufficiently  deep  to  afford  good  support. 

The  muscles  become  more  and  more  displaced,  and  such  as  are  unable 
to  functionate,  as  the  gluteal,  become  degenerated.  The  psoas,  iliacus,  and 
peri-trochanteric  muscles  are  contracted,  as  are  also  the  ligaments  and  fascias 
upon  the  anterior  portion  of  the  articulation. 

The  pelvis  is  suspended  by  the  capsules,  as  pointed  out  by  Volkmann, 
as  the  old-fashioned  stage-coach  was  hung  upon  its  leather  springs.  The 
pelvis  becomes  contracted  above  and  expanded  below,  and  the  iliac  bones 
are  carried  backward  and  upward. 

The  pelvic  changes  in  bilateral  congenital  dislocation  of  the  femora  have 
been  particularly  observed  by  KJeinwachter,  Schauta,  and  Lassman,  the  latter 
having  recorded  twenty-seven  cases.  The  anatomic  changes  in  the  pelvis  are 
produced  by  traction  of  the  muscles,  especially  the  psoas,  and  of  the  ligaments 
in  a  transverse  direction,  causing  a  lessening  of  the  inclination  of  the  pelvis, 
and  lumbar  lordosis  due  to  the  position  of  the  heads  of  the  femora.  Parvin 
states  that  tension  upon  the  pelvic  ring  causes  increase  in  the  transverse  diameter 
of  the  inlet,  and  flattening  of  the  pelvis,  with  necessary  shortening  of  the  true 
conjugate;  the  latter  diminution  being  increased  by  the  sinking  forward  of 
the  sacrum;  "because  of  this  the  promontory  is  also  more  marked."     The 


*  "Trans.  Amer.  Orth.  Assoc,"  vol.  xvi,  p.  23 


CONGENITAL  DISLOCATION  OF  THE  HIP.  849 

true  conjugate  is  rarely  below  9  cm.,  but  in  some  cases  has  been  reduced  to 
7  cm. 

The  characteristics  of  this  pelvis  are:  (i)  The  double  luxation  and  increase 
in  bi-trochanteric  diameter.  (2)  The  increased  transverse  diameters  both 
external  and  internal.  (3)  The  decreased  antero-posterior  diameters,  internal 
and  external.  (4)  The  greater  breadth  of  the  pubic  arch.  (5)  The  lessened 
depth  and  therefore  the  shortening  of  the  birth  canal.  (6)  The  lessening  of  the 
inclination  of  the  pelvis. 

The  mechanism  of  labor  is  said  by  Garrigues  to  be  much  like  that  in  the 
flat  rachitic  pelvis.  Labor  not  infrequently  ends  spontaneously,  but  there  may 
be  difiiculty  in  engagement  because  of  small  conjugate  or  malpresentation,  to 
which  these  cases  are  prone  because  of  the  lessened  inclination  and  pendulous 
abdomen.  In  only  nine  out  of  the  twenty-seven  cases  of  Lassman  was  there 
a  favorable  outcome. 

The  pelvis  is  usually  atrophied  on  both  sides  in  bilateral  dislocations.  The 
pelvic  bones  are  slender,  probably  from  the  same  defect  which  makes  the  ace- 
tabulum imperfect.  The  attachment  of  the  gluteal  muscles  being  nearer 
together  does  not  permit  of  the  normal  pull  upon  the  alee,  and  they  are  more 
nearly  vertical  than  normal. 

In  regard  to  the  changes  observed  in  the  pelvis  in  unilateral  congenital 
dislocation  of  the  femur  there  is  a  difference  of  opinion  among  the  various 
obstetric  writers,  some  of  whom,  Davis  among  them,  class  the  pelvis  as  similar 
to  the  Naegele  pelvis,  while  the  majority  define  the  deformity  produced  as  being 
exactly  opposite  to  that  produced  in  the  Naegele  pelvis.  The  pelvis  in  unilateral 
luxations  is  similar  in  character  to  the  coxalgic  pelvis,  and  is  very  much  like 
the  Sitz  pelvis — i.  e.,  one  in  which  one  lower  extremity  is  wanting. 

As  is  usual  in  unilaterally  deformed  pelves,  the  effect  upon  labor  is  marked 
and  the  diagnosis  of  the  deformity  easy.  Unilateral  deformity  of  the  pelvis 
was  observed  much  earlier  than  some  of  the  more  common  bilateral  deformities. 
Dionis,  in  his  "Traite  General  de  Acchouchemens,"  1708,  states  that  "the 
lame  who  have  one  of  the  hip  bones  higher  than  the  other  sometimes  have 
great  difficulty  in  labor  because  the  basin  formed  by  these  bones  is  not  exactly 
round  and  the  infant  is  obliged  to  redouble  its  efforts  in  order  to  go  through  the 
passage."  Hatin,  Paris,  1827,  also  mentions  the  pelvis  of  the  lame  in  "La 
Manouvre  de  Tous  les  Acchouchemens  contre  Nature." 

In  regard  to  the  anatomic  changes  there  is  a  great  difference  in  degree  and 
variety,  partly  depending  upon  the  degree  of  deformity.  The  weight  of  the 
55 


S50  ORTHOPEDIC  SURGERY. 

body  is  thrown  mainly  on  the  other  leg  and  the  corresponding  side  of  the 
pelvis  is  therefore  forced  upward.  When  the  head  of  the  femur  is  displaced 
forward,  the  anterior  half  of  the  pelvis  is  driven  inward  on  the  pelvic  canal. 
In  one  case  mentioned  in  the  "American  Text-Book  of  Obstetrics  "  the  head 
of  the  thigh  bone  projected  over  the  horizontal  ramus  of  the  pubis  into  the 
pelvic  inlet.  The  symphysis  is  drawn  to  the  affected  side  and  the  epitro- 
chanteric  line  may  lie  any  distance  above  the  os  pubis  and  even  reach  the 
iliac  spine.  The  posterior  iliac  spine  on  the  affected  side  approximates  the 
crest  of  the  sacrum.  The  deformity  is  greater  at  the  inlet,  but  may  be  very 
great  at  the  outlet  because  of  the  coccyx  being  pulled  forward  and  to  the 
affected  side  and  the  driving  in  of  the  symphysis  on  the  birth  canal.  The  inlet 
is  oval  in  shape,  as  in  the  Naegele  pelvis,  but  the  small  point  of  the  oval  is 
directed  toward  the  os  pubis  and  not  toward  the  sacrum.  In  other  words,  it 
is  precisely  the  opposite  diagonal  of  the  inlet  which  is  lessened:  The  antero- 
posterior diameter  is  not  very  greatly  diminished.  The  transverse  diameter 
is  somewhat  diminished.  The  Naegele  pelvis  also  differs  in  the  fact  that  the 
symphysis  is  in  this  case  pushed  toward  the  healthy  side  and  the  pubic  arch 
also  faces  in  the  same  direction. 

The  outlet  is  deformed '  sometimes  in  both  the  antero-posterior  (which  is 
now  not  coincident  with  the  antero-posterior  diameter  of  the  trunk)  and  the 
transverse  diameters.  The  coccyx  is  drawn  forward  and  upward,  the  pubic 
arch  is  decreased,  the  shape  of  the  arch  deformed,  and  the  spines  of  the  ischium 
are. pushed  inward  and  upward.  The  axis  of  the  pelvic  canal  is  atypical  and 
causes  anomalies  in  mechanism.  The  pelvis  is  not,  as  a  rule,  excessively  con- 
tracted, and  Prouvost  reports  that  forty  out  of  fifty  cases  end  spontaneously, 
contrasting  favorably  with  the  report  of  Litzman  in  Naegele  pelvis,  in  which 
there  were  22  deaths  in  28  cases  of  first  labor,  5  undelivered,  3  cases  dying  after 
second  labor,  and  2  after  sixth  labor.  The  mechanism  in  an  obliquely  con- 
tracted pelvis  is  similar,  as  a  rule,  to  that  in  a  generally  contracted  pelvis.  Even 
in  mUd  cases  there  is  great  danger  of  maternal  and  fetal  injury — in  fact,  the 
infant  mortality  is  very  high. 

In  unilateral  cases  there  is  usually  atrophy  of  the  aft'ected  side,  and  scoliosis 
is  present,  the  convexity  being  toward  the  affected  side,  and  in  some  instances 
a  compensatory  curve  may  form  in  the  dorsal  region. 

In  a  recent  case  of  pseudo-arthrosis  in  a  girl  of  sixteen,  with  which  I  as- 
sisted Hoffa,  the  head  was  well  formed,  only  slightly  flattened,  the  right  ligament 
was  wanting  on  one  side,  and  the  neck  was  very  short. 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


Sol 


Symptoms. 

The  affection  is  characterized  by  the  peculiar  gait  and  by  the  deformity. 

In  unilateral  dislocations  the  gait  becomes  an  exaggerated  limp,  the  limb 
is  short,  the  pelvis  flexed  and  tilted,  and  lordosis  and  scoliosis  are  present.  As 
the  patient  rests  the  weight  upon  the  affected  side  the  pelvis  sinks  dovmward 
and  forward,  and  as  the  pelvis  is  elevated  for  the  forward  movement  of  the  leg 
the  limb  lengthens  and  the  foot  remains  for  an  interval  upon  the  ground.     Walk- 


FiG.  653. — Bilateral  Dislocation  of  Hips  (Side  View). 


Fig.  654. — Same  (Back  View). 


ing  is  difficult,  and  children  subject  to  this  deformity  become  fatigued  easily 
and  complain  of  pain  after  walking  one  or  two  miles. 

Viewed  from  in  front,  the  patient  standing,  the  shoulder  on  the  afl'ected 
side  is  lowered,  the  pelvis  is  tilted  if  the  foot  rests  upon  the  floor,  but  it  remains 
level  if  the  subject  compensates  by  allowing  hyperextension  of  the  sound  limb 
in  a  position  of  genu  recurvatum,  or  by  raising  the  heel.  The  trochanter  is 
prominent  on  the  affected  side.  The  limb  is  atrophied  throughout,  and,  ac- 
cording to  some,  hemiatrophy  of  the  cranium,  face,  and  thorax  may  also  be 
present. 


852  ORTHOPEDIC  SURGERY. 

Viewed  from  behind,  the  prominence  of  the  trochanter  is  more  apparent, 
and  the  lordosis  and  scoliosis  are  observed  unless  the  patient  compensates. 

In  the  recumbent  position  the  dislocated  joint  is  excessively  mobile,  free 
from  swelling  or  pain.  Measured  from  the  anterior  spine  to  the  malleolus, 
the  luxated  limb  is  shorter  than  the  sound  limb,  and  if  an  imaginary  line  be 
drawn  from  the  anterior  spine  to  the  tuberosity  of  the  ischium,  the  trochanter 
is  from  §  to  2\  inches  above,  but  may  frequently  be  brought  down  by  traction. 
In  some  instances  a  depression  may  be  felt  and  observed  in  the  inguinal  region 
over  the  normal  position  of  the  head  of  the  femur.  The  knee  is  adducted  and 
the  foot  rotated  outward.  Adduction  of  the  hip  is  increased,  abduction  is 
limited,  and  all  the  other  movements  are  exaggerated. 

In  bUateral  cases  the  child  walks  very  late,  and  waddles  with  a  peculiar, 
goose-like  gait,  with  marked  lordosis,  flexion  of  the  pelvis,  and  protrusion  of 
the  abdomen.  In  a  few  instances  some  of  the  symptoms  present  in  unilateral 
deformity  are  observed  in  bilateral  cases  on  the  side  most  affected. 

Viewed  from  in  front,  the  abdomen  is  pendant,  the  hip  prominent,  the 
trochanters  are  conspicuous,  and  the  lower  extremities  relatively  short,  the  body 
and  arms  relatively  long,  the  knees  flexed  and  adducted,  the  feet  turned  out- 
ward. The  perineum  is  very  broad,  leaving  a  triangular  space  betM^een  the 
thighs,  with  the  base  up. 

Viewed  from  behind,  the  lordosis  is  excessive,  or  moderated,  depending 
upon  the  position  of  the  head  of  the  femur,  whether  backward,  upward,  or 
forward.  The  prominence  of  the  trochanters  is  accentuated  by  the  atrophy  of 
the  gluteal  muscles  and  the  adduction  of  the  femur.  The  degree  of  lameness 
and  disability  varies  greatly,  and  increases  with  age,  but  is  never  so  marked  as 
in  unilateral  deformity.  In  very  rare  instances,  according  to  the  observations 
of  Redard,  inflammation  may  supervene  and  the  subject  become  incapacitated 
by  severe  attacks  of  pain. 

Pain  in  the  muscles  about  the  hip,  in  the  lumbar  region,  increased  upon 
locomotion,  is  common  in  older  subjects,  and  most  adults  have  been  compeUed 
to  use  crutches  or  to  be  confined  to  bed  at  some  time  during  their  existence. 
In  young  people  the  freedom  from  disability  in  bilateral  dislocations  is  some- 
times surprising.  I  have  seen  a  child  of  tw^elve  jump  with  agility  from  a  table 
to  the  floor,  and  another  patient  of  sixteen  could  dance  and  skate  without  any 
inconvenience  whatever. 


CONGENITAL  DISLOCATION  OF  THE  HIP.  853 

Diagnosis. 

In  very  young  children  the  affection  is  frequently  overlooked,  but  in  adults 
the  diagnosis  can  often  be  made  at  a  glance.  The  diagnosis  rests  upon  the 
history,  the  prominence  of  the  trochanter,  excessive  mobility  of  the  joint,  width 
of  the  pelvis,  and  especially  the  position  of  the  trochanter  in  its  relation  to 
Nelaton's  line,  drawn  from  the  anterior  superior  spinous  process  of  the  Uium 
to  the  tuberosity  of  the  ischium.  Instead  of  being  in  a  line,  the  trochanter 
is  usually  from  one  and  a  half  to  two  inches  above.  Especially  valuable  is 
the  Rontgen-ray  photograph  in  diagnosing  this  affection. 

The  unilateral  displacement  may  be  confounded  with  traumatic  disloca- 
tion, acute  epiphysitis,  separation  of  the  epiphysis,  hip  disease,  and  infant 
paralysis,  from  which  the  following  differences  wUl  distinguish  it.  In  acute 
epiphysitis  of  the  head  and  neck  of  the  femur  the  physical  signs  are  identical 
with  congenital  dislocation,  but  the  history  of  a  general  septic  infection,  usually 
through  the  umbilical  cord,  with  local  suppuration,  will  aid  in  arriving  at  a 
correct  diagnosis.  An  ^c-ray  photograph  wUl  be  especially  valuable  as  showing 
the  entire  absence  of  the  epiphysis  on  the  aff'ected  side.  The '  discovery  of  a 
cicatrix  from  an  incision  into  the  joint,  or  from  spontaneous  rupture  of  the 
joint  contents,  would  be  suggestive,  and  where  this  is  absent  cicatrices  may 
usually  be  found  over  other  epiphyses  which  have  been  the  seat  of  coincident 
suppuration. 

In  traumatic  dislocations  the  history  of  an  obstetric  injury  and  the  early 
fixation  of  the  joint  are  distinguishing  points.  The  firmness  of  the  joint  after 
reduction  wUl  confirm  the  origin  of  the  injury.  Separation  of  the  epiphysis 
will  be  indicated  by  fixation  of  the  limb,  swelling  of  the  joint,  and  eversion  and 
shortening  of  the  limb.  In  hip  disease  the  spasm,  atrophy,  deformity,  pain, 
abscess,  and  other  symptoms  are  distinctive.  In  infantile  paralysis  the  gait, 
laxity  of  the  hip-joint,  and  inequality  of  the  limbs  resemble  dislocation,  and 
where  paralytic  dislocation  exists  also,  the  condition  is  confusing;  but  the 
history  of  paralysis,  the  cold  and  atrophied  limb,  the  laxity  of  all  the  joints  of 
the  limb,  and  particularly  the  electric  reactions  serve  to  distinguish  it. 

The  bUateral  affection  must  be  distinguished  from  bow-legs,  coxa  vara, 
and  pseudo-muscular  hypertrophy.  In  bow-legs  the  waddling  walk  and  marked 
lordosis  resemble  this  affection,  but  the  normal  condition  of  the  hip  is  decisive, 
although  both  affections  may  coexist.  Congenital  dislocation  of  the  hip  will 
frequently  be  mistaken  for  adolescent  coxa  vara  of  rachitic  origin,  on  account 
of  the  high  position  of  the  trochanter  and  the  limitation  of  abduction  of  the 


854  .  ORTHOPEDIC  SURGERY. 

limbs.  The  fact  that  the  trochanter  cannot  be  drawn  down  by  traction,  and 
the  head  of  the  femur  can  be  felt  in  its  proper  relation  to  the  acetabulum,  should 
render  the  diagnosis  sufficiently  clear,  but  if  any  doubt  exist,  the  Rontgen-ray 
picture  will  remove  it.  The  marked  lordosis  and  the  imperfect  use  of  the  lower 
extremities  in  young  children  suffering  from  pseudo-muscular  hypertrophy  may 
resemble  this  deformity,  but  the  normal  position  of  the  head  of  the  femur,  the 
slight  prominence  of  the  trochanters,  the  excessive  development  of  the  calf 
muscles,  and  atrophy  of  the  latissimus  dorsi,  teres  major,  and  lower  part  of 
the  pectoralis  major,  would  serve  to  differentiate  the  latter  affection. 

Prognosis. 

When  Dupuytren  in  1826  pronounced  this  affection  not  only  incurable 
but  not  amenable  to  treatment,  he  expressed  the  opinion  which  was  subse- 
quently held  by  most  competent  surgeons  for  nearly  three-quarters  of  a  century. 
The  therapeutics  of  this  affection,  however,  have  made  such  progress  of  late 
years  that  instead  of  being,  as  formerly  considered,  an  incurable  affection,  it 
may  now  be  considered,  within  certain  limits,  as  curable.  The  percentage  of 
recoveries  depends  upon  the  age  of  the  individual  and  the  amount  of  deformity 
of  the  head  and  neck  of  the  fernur.  Before  the  age  of  seven  years  the  percentage 
of  cured  cases  is  large;  after  that  age  the  chances  of  recovery  diminish  rapidly. 
Much  will  depend  upon  the  muscular  development,  shortening,  and  rigidity. 
The  possibility  of  reduction  is  limited  by  the  age  of  the  individual.  In  bilateral 
cases  the  age  limit  for  forcible  reduction  should  be  from  the  ages  of  seven  to 
eight  years,  but  in  unilateral  cases  the  age  limit  may  be  extended  to  from  nine 
to  ten  years.  Where  there  is  great  shortening,  with  rigidity,  the  open  operation 
is  performed,  preferably  between  the  ages  of  from  four  to  six  years.  Wliere 
there  is  deformity  of  the  head  or  neck  of  the  femur,  an  improved  functional 
result  may  sometimes  be  obtained  even  where  the  anatomic  results  may  be 
faulty,  but  a  perfect  result  is  impossible  under  any  form  of  treatment.  These 
constitute  at  least  20  per  cent,  of  all  cases.  Prior  to  or  after  puberty  the  operation 
for  the  improvement  of  the  angle  of  deformity  may  be  undertaken. 

In  considering  the  possibility  of  cure  in  any  particular  instance,  the  result 
in  the  event  of  failure  should  be  compared  with  the  condition  of  the  individual 
if  no  operation  has  been  undertaken.  Without  treatment  the  deformity  appears 
either  to  remain  stationary  or  to  grow  somewhat  worse,  no  spontaneous  cures 
ever  having  been  reported. 

Out  of  364  cases  of  unilateral  dislocations  reported  in  1905  by  Lorenz, 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


855 


218  gave  anatomically  good  results,  while  127  showed  subspinal  positions 
(anterior  reluxation,  upward  and  outward)  and  19  showed  lateral  appositions. 
"Out  of  158  cases  of  bilateral  dislocations,  70  showed  good  anatomic  results 
on  both  sides,  19  resulted  in  subspinous  positions  on  both  sides,  7  showed 
lateral  apposition  on  both  sides,  49  resulted  in  anatomically  good  results  on 
one  side  while  the  other  side  became  subspinous;  in  4  cases  one  side  became 
anatomically  replaced  while  the  other  side  showed  lateral  apposition;  in  9 
cases  one  side  was  subspinous,  the  other  lateral  apposition.     Taking  all  the 


Fig.  655. — Skiagraph  showing   Bilateral  Dislocation  of  Hip  (before  Operation)  (Wilson). 


hips  together  (364  +  twice  158  =  680),  358  of  these  showed  good  anatomic 
results,  i.  e.,  52.6  per  cent. — a  good  half  of  the  cases." 

Hoffa  reports  250  cases  of  unilateral  dislocation  in  which  there  were  75 
good  anatomic  and  functional  results,  no  good  functional  results,  and  65, 
unsatisfactory  results,  making  75  per  cent,  of  satisfactory  results. 

Out  of  65  cases  of  bilateral  dislocation  there  were  7  good  anatomic  and 
functional  results,  32  good  functional  results,  10  good  functional  results  on 
one  side  with  reluxation  of  the  other  side,  and  18  reluxations  of  both  sides, 
thus  making  about  60  per  cent,  of  satisfactory  results. 


856  ORTHOPEDIC  SURGERY. 

Ho£fa  reports  having  performed  the  open  operation  for  reposition  of  the 
dislocation  where  the  bloodless  method  had  been  unsuccessful,  and  gives  80 
per  cent,  of  satisfactory  results  in  all  his  cases  of  congenital  dislocation,  by 
the  use  of  the  combined  methods. 

Treatment. 

The  treatment  of  congenital  dislocation  of  the  hip  may  be  divided  into: 
Treatment  by  extension  and  apparatus. 
Treatment  by  forcible  reduction. 
Treatment  by  operative  methods. 


Fro.  656. — Skiagraph  showing  Bilateral  Dislocation  of  Hrp  (after  Operation). 

Treatment  by  Extension  and  Apparatus. — To  Buckminster  Brown, 
of  Boston,  belongs  the  credit  of  having  first  obtained  a  perfect  cure  by  the 
use  of  extension  and  apparatus.  Cases  have  been  reported  in  which  benefit 
has  resulted  from  the  use  of  continuous  prolonged  extension,  but  in  all  of  these 
cases  there  appears  to  have  been  some  doubt  as  to  the  ultimate  result.  More- 
over, the  possibility  of  cure  is  so  slight  and  the  liability  of  relapse  so  great  that 
the  subject  may  be  dismissed  as  unpractical.  Corset  and  pelvic  bands  of  plaster- 
of-Paris,  silicate,  or  felt  have  been  much  advocated,  especially  by  the  Germans. 
These  have  their  uses  where  nothing  more  radical  or  curative  can  be  employed. 


CONGENITAL  DISLOCATION  OF  THE  LIIP. 


857 


A  plaster  mold  may  be  made  while  the  patient  is  suspended,  and  from  this  a 
poroplastic  splint  made  which  may  be  worn  during  the  day.  Modifications  of 
the  long  extension  splint  have  been  employed  by  many. 

Treatment  by  Forcible  Reduction. — To  Post,  of  Boston,  belongs  the 
credit  of  having  first  forcibly  reduced  a  congenital  dislocation  under  an  anes- 
thetic; but  to  Hoffa,  of  Berlin,  belongs  the  honor  of  having  first  performed, 
in  1890,  the  open  operation  of  reposition,  with  success.  This  operation,  which 
consisted  in  part  of  reducing  the  dislocation  by  manipulation,  was  subsequently 
modified  by  Lorenz,  of  Vienna. 
and  by  Hoffa  himself,  and  has 
been  so  improved  as  to  now  con- 
sist, in  early  life,  of  a  so-called 
bloodless  reposition. 

At  present  there  are  three 
difterent  methods  of  forcible 
reduction  which  are  in  general 
use  and  of  which  short  descrip- 
tions should  be  given : 

1.  The      method     of 

Paci. 

2.  The      method     of 

Lorenz. 

3.  The      method     of 

Hoft'a. 

The  method  of  Paci. 
This  consists  of  four  parts — 
flexion,  abduction,  external  ro- 
tation, and  extension.  Fig.  657.- 

First  part:  The  patient 
being  placed  in  the  recumbent 

position  upon  the  edge  of  a  bed,  or  upon  a  flat  surface,  the  pelvis  is  firmly  secured 
by  the  assistants  and  the  thigh  is  then  fully  flexed  on  the  trunk  and  the  leg  on  the 
thigh.  This  produces  a  relaxation  of  the  muscles  passing  from  the  trunk  to  be 
inserted  into  the  femur  and  leg.  As  a  result  of  the  flexion  the  femur  is  carried  into 
the  iliac  fossa  and  is  gradually  brought  to  the  insertion  of  the  Y  ligament.  The 
head  of  the  femur  is  thus  moved  downward  to  the  edge  of  the  acetabulum.  The 
descent  of  the  head  may  be  increased  by  making  light  pressure  upon  the  knee. 


Brace  for  Congenital  Dislocation  of  Hips 
—AFTER  Tenotomy  of  Adductors. 


858  ORTHOPEDIC  SURGERY 

Second  part:  The  surgeon  then  moves  the  femur  outward  in  a  position  of 
abduction,  the  object  being  to  place  the  head  of  the  femur  on  an  anterior  plane 
to  the  edge  of  the  acetabulum,  or  against  its  posterior  border,  if  on  account 
of  the  deformity  of  the  neck  of  the  femur  and  the  resistance  of  the  muscles 
the  head  has  been  arrested  at  this  point. 

Third  part:  The  limb  being  still  in  marked  abduction,  the  femur  is  carried 
by  slow  and  gradual  movement  of  outward  rotation  until  the  femoral  head  is 
carried  on  an  anterior  plane  nearly  to  the  acetabulum. 

Fourth  part:  The  surgeon,  using  the  edge  of  the  table  as  a  support,  slowly 
extends  the  thigh,  one  hand  pressing  on  the  knee  and  the  other  holding  the 
foot  and  flexed  limb,  the  whole  limb  being  rotated  outward  until  the  femoral 
head,  supported  by  the  anterior  muscles  of  the  thigh,  is  placed  forward,  and 
the  thigh  can  be  fully  extended  parallel  with  the  table.  The  head  of  the  femur 
after  its  reduction  is  retained  in  its  new  position  by  the  irritation  and  strain 
of  the  muscles  produced  by  the  movements.  The  movements  should  be  exe- 
cuted with  extreme  slowness  and  without  roughness,  and  in  such  a  manner  as 
to  avoid  laceration.  Anesthesia  is  not,  as  a  rule,  necessary.  A  silicate  of 
potassium  dressing  is  applied  for  one  month,  after  which  extension  is  continued 
by  means  of  a  Volkmann  apparatus  for  three  months.  At  the  end  of  this  period 
certain  walking  exercises  are  prescribed,  with  the  use  of  crutches,  and  later 
the  patient  walks,  with  or  without  a  cane. 

By  this  method  cures  are  said  to  be  eft'ected  in  one  year,  the  first  reduction 
having  been  maintained.  The  method  is  most  suitable  for  very  young  children 
who  have  not  yet  used  their  limbs.  The  percentage  of  cures  reported  is  low 
compared  with  that  of  the  other  methods. 

The  method  of  Lorenz.    The  treatment  by  the  Lorenz  method  consists  of: 

1.  Preparatory  treatment. 

2.  Reduction. 

3.  Retention. 

4.  After-treatment. 

Preparatory  treatment:  The  patient  should  be  very  carefully  selected  as 
regards  age,  the  amount  of  contraction  of  the  muscles,  and  the  amount  of  shorten- 
ing. The  age  limit  for  cases  of  double  dislocation  is  seven  to  eight  years,  the 
preferable  time  for  the  operation  being  between  four  and  six  years  of  age.  In 
unilateral  cases,  after  a  long  period  of  preliminary  treatment  the  age  limit 
may  be  extended  to  nine  or  ten  years. 

The  preliminary  treatment,  which  consists  in  making  extension  by  means 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


859 


of  six-pound  weights,  sliould  be  carried  out  for  from  ten  days  to  twenty 'days, 
according  to  tiie  severity  of  the  case.     The  long  muscles  must  be  stretched, 


Fig.  658. — Table  for  LoeexNZ  Reduction,  showing  Appliances  (Wilson). 


Fig.  639. — Tearing  of  Adductor  Tendons  (Wilson). 


particularly  the  adductors,  as  this  renders  the  reduction  less  difficult.    The 
resistance  of  the  anterior  muscles  may  be  overcome  by  stretching,  and  by  bending 


860 


ORTHOPEDIC  SURGERY. 


the  knee.  In  many  cases  it  is  best  to  perform  a  preliminan,-  subcutaneous 
tenotomy  of  the  adductors,  under  anesthesia,  two  weeks  before  the  final 
reduction,  and  if  there  is  much  contraction,  the  hamstrings,  the  sartorius,  and 
the  tensor  fascia  femoris  may  be  divided.  In  young  children  and  in  selected 
cases  these  preliminary  tenotomies  need  not  be  performed,  but  the  adductors 
and  other  resisting  structures  may  be  torn  at  the  time  of  the  reduction. 

To  perform  the  reduction  of  the  dislocation  one  should  be  provided  with 
a  low  firm  table,  a  small  padded  stool,  an  oak  triangular  wedge,  4  by  5  by  9 


Fig.  660. — Stretchin-g  Hamsteixg  Texdon"S   (Wilson). 


inches,  the  upper  sharp  edge  of  which  is  covered  with  leather,  a  pelvic  stool, 
a  skein  of  hea^y  yam,  and  a  large  sand-bag. 

The  operation  itself  consists  of  five  distinct  parts,  Avhich  must  be  employed 
in  the  order  given : 

1.  Hyperabduction  and  tearing  of  the  adductors.  The  pelvis  is  fixed  by 
the  assistant,  the  limb  is  forcibly  abducted,  and  the  adductor  muscles  are  sep- 
arated from  their  attachments  to  the  peh-is,  by  manual  pressure,  if  they  have 
not  been  previously  tenotomized. 

2.  H}'perflexion.  The  patient  being  in  the  prone  position,  the  lower  ex- 
tremity is  slowly  and  forcibly  flexed  until  the  foot  touches  the  ear,  in  a  similar 
manner  to  the  method  employed  in  stretching  the  sciatic  nen"e. 


CONGENITAL  DISLOCATION  OF  THE  HIP.  861 

3.  Hyperextension.  The  patient  lying  upon  the  opposite  side,  the  lower 
extremity  is  forcibly  extended,  the  knee  being  bent. 

4.  Traction.  The  patient  lying  in  the  prone  position,  forcible  manual 
traction  is  made  upon  the  extremity,  or  by  means  of  a  skein  of  yam  fastened 
about  the  ankle,  the  pelvis  being  fixed  by  the  hand  of  an  assistant. 

5.  Reduction.  The  reduction  of  the  head  of  the  femur  into  the  acetabulum 
is  accomplished  by  placing  a  triangular  wooden  block  beneath  the  trochanter, 
the  patient  lying  in  the  prone  position,  and  strongly  abducting  the  thigh.  After 
the  head  of  the  femur  is  reduced  the  anterior  part  of  the  capsule  is  enlarged 


Fig.  661. — Stretching  Anterior  Muscles  (Wilson). 

by  hyperabduction  of  the  thigh  together  with  rotation.  As  a  test  that  the 
reduction  has  been  accomplished,  the  knee-joints  cannot  be  extended  beyond 
a  right  angle. 

The  dressing:  The  limbs  are  held  in  a  hyperabducted  position  with  the 
knees  flexed,  by  means  of  a  heavy  plaster-of- Paris  dressing.  They  are  first 
encased  in  stockinet  drawers,  cotton  batting,  and  muslin  rollers,  the  perineum 
being  entirely  covered  by  figure-of-eight  turns.  A  movable  strip  of  muslin  is 
inserted  within  the  stockinet  drawers  with  a  free  end  extending  above  and 
below  for  the  purpose  of  massage  and  cleanliness.  From  twelve  to  fifteen 
plaster-of-Paris  bandages  are  applied,  completely  covering  the  muslin  rollers. 


862 


ORTHOPEDIC  SURGERY 


The  method  of  applying  these  plaster  bandages  is  peculiar.  In  unilateral 
cases  the  roller  begins  at  the  anterior  superior  spine  of  the  sound  side,  is  carried 
across  the  pubis,  over  the  inner  surface  of  the  affected  knee,  around  which  it 
is  passed,  and  along  the  posterior  surface  of  the  body  to  the  starting-point.  It 
is  then  carried  a  second  time  across  the  front  to  the  affected  knee,  around  which 
it  is  passed.  Circular  turns  are  then  applied  to  the  affected  side  untU  the  pelvis 
is  reached,  when  this  part  is  entirely  covered  by  figure-of-eight  turns. 

In  bilateral  cases  the  application  of  the  plaster  bandage  is  stUl  more  com- 
plicated.   Starting  from  the  anterior  superior  spine  of  the  right  side,  it  is  carried 


Fig.  662. — Redtjction  by  Meaxs  of  the  Trochanteric  Block  (Wilson). 


back  of  the  right  limb,  around  the  right  knee,  across  the  pubis,  to  the  left  knee, 
around  which  it  is  passed.  The  left  thigh  is  then  covered  in  with  spirals,  the 
bandage  then  being  carried  across  the  pubis  in  a  figure-of-eight  turn  to  the 
lower  third  of  the  right  thigh.  Circulars  are  applied  to  the  right  thigh,  and 
the  entire  pelvis  is  covered  in  by  figure-of-eight  turns.  This  is  best  illustrated 
by  reference  to  Fig.  666. 

After  the  application  of  the  plaster  bandages  a  large  fenestrum  is  removed 
from  the  perineal  region,  and  the  dressing  trimmed  over  the  popliteal  spaces, 
and  above  in  front  and  behind.     This  dressing;  should  remain  on  for  six  months. 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


863 


As  soon  as  the  soreness  and  discomfort  have  disappeared,  which  will  be 
within  a  weeli  if  tenotomies  have  not  been  performed,  and  shortly  after  two 
weeks  if  they  have  been  performed,  the  patient  should  be  encouraged  to  use 
the  parts.  The  great  advantage  of  this  method,  which  is  knov^Ti  as  the  func- 
tional weight-bearing  method,  is  that  the  muscles  are  brought  into  action  soon 
and  atrophy  does  not  occur. 

In  unilateral  cases  a  high  shoe,  raised  by  means  of  a  block  four  or  five 


Fig.  663. — Patient  with  Cast  Applied  (Wilson). 


inches  in  height,  should  be  worn  on  the  affected  foot,  so  that  the  patient  may 
be  able  to  walk,  and  in  bilateral  cases  a  small  stool  on  wheels  should  be  used, 
by  means  of  which  the  patient  can  propel  himself  about  and  make  use  of  the 
muscles. 

In  regard  to  the  after-treatment,  the  first  cast  should  be  removed  at  the 
end  of  six  months,  or  sometimes  it  may  be  removed  after  four  months,  and 
after  its  removal  the  use  of  a  support  may  be  discontinued  entirely,  or,  what 
is  better,  the  first  cast  may  be  replaced  by  another  which  will  hold  the  limb 


S64  ORTHOPEDIC  SURGERY. 

in  a  position  midway  between  abduction  and  adduction,  and  midway  between 
flexion  and  extension,  that  is,  in  a  position  of  abduction  of  45  degrees  and. of 
flexion  from  115  degrees  to  135  degrees.  The  block  which  has  been  worn 
should  be  reduced  correspondingly,  and  subsequently  it  is  gradually  reduced 
until  it  is  only  one  inch  in  height. 

This  second  cast  is  worn  for  from  four  to  six  months,  and  upon  its  removal 
at  the  end  of  this  period,  the  patient  walks  with  the  limb  extended  but  with 
the  foot  still  everted.  During  the  daytime  he  remains  without  any  apparatus 
or  support,  but  in  doubtful  cases  it  is  best  to  apply  at  night  a  removable  ab- 


FiG.  664. — Patient  with  Dressing  Completed   (Wilson). 

duction  cast,  which  may  be  made  of  plaster,  leather,  or  celluloid,  in  order  to 
prevent  any  possible  relapse  during  sleeping  hours. 

At  this  time  certain  gymnastic  exercises  must  be  begun.  The  importance 
of  very  careful  gymnastic  treatment,  together  with  massage,  cannot  be  over- 
estimated, since  there  is  a  continuous  struggle  against  contracture  and  anky- 
losis, and  an  effort  to  produce  a  good  muscular  support.  The  removal  of  the 
cast  soon  enables  the  muscular  system  to  regain  its  strength,  and  although  in 
some  cases  brilliant  results  have  been  obtained  with  but  little  after-treatment, 
yet  the  value  of  mechano-therapy  should  not  be  lightly  dismissed,  for  in  general 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


865 


the  completeness  of  the  cure  depends  upon  the  most  perfect  attainable  restoration 
of  the  muscular  system.  The  reduction  may  be  faultless  from  an  anatomic 
standpoint,  and  yet  the  result  from  a  prosthetic  point  of  view  is  not  entirely 
satisfactory  to  the  surgeons. 

The  pelvic  trochanteric  muscles  require  the  most  attention,  particularly 
the  abductors,  and  the  development  of  these  muscles  may  be  accomplished  by 
certain  set  exercises.  The  patient  in  a  standing  position  may  take  an  active 
passive  movement  of  abduction  by  a  free  move- 
ment of  the  affected  limb  in  a  frontal  plane, 
throwing  the  limb  backward  and  drawing  it  for- 
ward. Another  very  valuable  movement  is  the 
active  abduction  of  the  limb,  the  patient  lying 
on  the  side  with  the  affected  limb  upward.  The 
affected  limb  is  then  slowly  raised,  the  effect  of 
this  exercise  being  increased  by  slight  resistance 
on  the  part  of  the  operator.  Later  the  active 
abduction  may  be  improved  by  teaching  the 
child  to  stand  on  the  affected  limb  and  to  draw 
the  opposite  side  of  the  pelvis  up  high  with  the 
gluteal  muscles  contracted,  and  to  hop  upon  the 
affected  limb.  This  is  at  first  difficult,  but  with 
persistence  these  exercises  may  be  accomplished. 

The  foregoing  exercises  are  to  be  used  for 
unilateral  cases.  In  bilateral  cases  the  following 
exercises  have  proved  very  valuable  in  restoring 
the  muscles. 

First,  the  patient,  lying  on  his  back,  abducts 
his  limbs  with  as  little  assistance  as  possible,  the 
limbs  sliding  along  the  surface  of  the  table.  A 
second  movement  consists  in  taking  this  same 

exercise  but  liftiag  the  limbs  in  a  diagonal  manner  from  the  table  as  they  are 
moved  outward.  A  third  movement  consists  of  the  same  exercise,  but  carrying 
the  limbs  in  a  still  further  abducted  position.  Additional  exercises  may  be 
given  with  advantage,  the  child  lying  upon  its  face.  In  this  position  he  flexes 
his  knees  in  such  a  manner  as  to  raise  the  thighs  from  the  table  and  in  this  posi- 
tion abducts  the  limbs.  This  movement  may  be  increased  so  that  the  pelvis 
and  the  entire  lower  extremities  are  raised  from  the  table. 

56 


Fig.  665. — LoRENZ  Cast  for  Uni- 
lateral Dislocation  of  the 
Hip  (Wilson). 


866  ORTHOPEDIC  SURGERY. 

Massage  should  be  used  from  the  time  of  the  removal  of  the  second  fixation 
bandage.    Both  friction  and  kneading  may  be  employed  with  benefit. 


Fig.  666. — Diagram  of  Turns  of  Plaster  Bandage  (Lorenz). 
I,  First  turn  of  bandage;  2,  spirals  of  left  thigh;  3,  spirals  of  right  thigh; 
4  and  5,  figtire-of-eight  turns  of  pelvis. 


Fig.  667.— Frame  for  Unilateral  Dislocation  (Heuss-  Fig.  668.— Fr.ame  for  Bilateral   Dislocation   (Heuss 

ner).  ner). 


The  patient  walks  with  the  foot  everted  for  from  eighteen  months  to  a 
year  after  the  reduction  has  been  accomplished.     In  some  individual  cases  the 


CONGENITAL  DISLOCATION  OF  THE  HIP.  867 

foot  may  be  allowed  to  turn  forward  of  its  own  accord,  but  in  others  it  will  be 
necessary  to  educate  the  patient  to  walk  properly.     WTien  the  surgeon  is  sure  that 


Fig.  669. — Active  Abduction  for  Unilateral  Dislocation  (Lorenz). 


Fig.  670. — Active  Hyperabduction  por  Bilateral  Dislocation  (Lorenz). 

the  reduction  is  secure,  the  foot  may  be  permitted  to  assume  its  normal  position 
approaching  the  frontal  plane. 

The  full  period  of  treatment  by  the  Lorenz  method  would  extend  over  a 
period  of  about  two  years,  which  would  be  the  same  as  in  the  older  traction 


868 


ORTHOPEDIC  SURGERY 


methods.  But  the  great  advantage  of  this  method  of  treatment,  the  function- 
weight-bearing,  is  that  the  patient  uses  the  limbs  within  two  or  three  weeks 
after  the  reduction,  and  the  restoration  of  the  muscular  power  is  more  rapidly 
obtained. 

Electricity  is  of  no  particular  value  as  a  part  of  the  treatment,  except  where 
there  has  been  an  injury  to  the  nerves. 

The  difficulties  and  dangers  incident  to  the  manual  reduction  of  congenital 


Fig.  671. — Bilateral  Dislocation'.     Back\'ie\v. 


Fig.  672. — BiL..\TER.AL  Dislocation.     Side  View. 


dislocation  of  the  hip  are  apt  to  be  underestimated  by  the  unskilful  on  account 
of  the  apparent  simplicity  of  the  operation  in  the  hands  of  the  skilful  surgeon. 
That  it  should  not  be  undertaken  hghtly  is  demonstrated  by  the  number  of 
accidents  which  have  occurred  even  under  skilful  hands.  Lorenz  in  1900 
reported  450  cases,  with  two  deaths  apparently  due  to  the  manipulation,  in 
addition  to  which  there  were  fractures  of  the  femur  and  pelvic  bones,  and  paral- 
yses of  the  anterior  crural  and  sciatic  nerves,  and  one  case  of  total  gangrene 
of  the  lower  extremity.     Hoffa  reported  to  the   German   Congress  in   1899, 


CONGENITAL  DISLOCATION  OF  THE  HIP.  869 

injuries  to  the  soft  parts,  fractures,  separation  of  the  epiphyses,  paralysis  of 
the  anterior  crural  and  sciatic  nerves,  and  suppuration  of  the  hematomas  at 
the  seat  of  the  ruptured  adductors.     He  reports  one  death. 

The  fractures  do  not  interfere  with  the  recovery,  and  the  paralysis  of  the 
anterior  crural  usually  recovers  within  the  period  of  the  first  dressing,  or  before 
the  end  of  six  months.  In  paralysis  of  the  sciatic  nerve  and  its  branches  the 
prognosis  is  more  grave;   and  if  it  be  due  to  rupture  of  the  nerve,  unless  this 


Fig.  673. — Bilateral  Dislocation,  showing  Result  of  Operation. 

is  repaired  it  may  be  permanent.  As  a  rule,  however,  recovery  from  this  con- 
dition ensues  also. 

In  my  own  personal  experience  of  quite  a  number  of  cases  none  of  these 
accidents  have  occurred.  But  I  have  seen  an  instance  of  the  obstruction  of 
the  venous  circulation  lasting  for  an  hour,  and  also  ankylosis  and  suppuration 
from  the  hematomas. 

Lorenz  reports  50  per  cent,  of  functional  cures  by  his  method,  and  Hoflfa 
claims  80  per  cent,  of  successful  results  by  his  different  methods  of  forcible 
reduction,  and  the  open  operation. 


870 


ORTHOPEDIC  SURGERY. 


The  method  of  Hoffa.  This  method  is  a  modification  of  that  of  Lorenz. 
Hoffa,  after  the  example  of  Kummel,  omits  all  preliminary  extension  and  begins 
directly  with  the  abduction  of  the  leg.  With  the  patient  in  the  recumbent 
position  the  leg  is  carried  back — abducted  at  a  right  angle- — and  strongly  rotated 
outward,  to  a  horizontal  position,  toward  the  buttocks,  the  movement  being 
that  of  a  pump-handle;  and  at  the  same  time  gradual  hyperextension  is  made 
upon  the  leg.  In  this  way  the  acetabulum  is  thoroughly  widened,  and  the 
spanning  capsular  wall  is  stretched.     By  this  method  reduction  of  congenital 


Fig.  674. — Forcible  Correction  for  Congenital  Dislocation  (Hofta).    .\bduction. 


dislocations  has  been  accomplished  in  older  subjects  where  the  Lorenz  method 
has  not  succeeded. 

Another  method  employed  by  Hoffa  is  based  upon  the  distinction  recently 
made  by  Lorenz  himself  between  a  reposition  by  the  "free-hand"  or  on  the 
wedge-shaped  block.  In  employing  the  free-hand  procedure  the  pelvis  is  fixed 
by  an  assistant  by  pressing  it  firmly  against  the  table.  The  operator  then 
seizes  the  under  end  of  the  thigh — bent  at  a  right  angle  and  slightly  rotated 
inward — ^with  one  hand,  while  with  the  thumb  of  the  other  hand  pressure  is 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


871 


made  upon  the  trochanter.  With  the  hand  holding  the  thigh  a  powerful  pull 
is  given  toward  the  thigh,  and  perpendicular  to  the  long  axis  of  the  body,  median 
pressure  being  continued  by  the  thumb  upon  the  trochanter,  and  at  the  same 
time  the  leg  is  strongly  abducted.  After  one  or  more  repetitions  of  this  move- 
ment the  reposition  is  accomplished. 

Mechanical  Reduction. — In  older  subjects  it  is  sometimes  necessary  to 
resort  to  mechanical  aids  to  accomplish  reduction  in  order  to  avoid  fractures 
and  injuries  to  the  nerves  and  vessels.     The  most  efficient  apparatus  of  this 


Fig.  675. — Same  as  Fig.  674;  Rotation  Outward. 


kind  is  one  devised  by  Mr.  Ralph  W.  Bartlett,  of  Boston.*  It  consists  essen- 
tially of  a  perineal  plate,  adjustable  cylinders,  and  a  traction  rod,  together 
with  a  side  arm  which  makes  pressure  upon  the  trochanter  in  a  forward  and 
downward  direction.  Bradford  and  Lovett  have  reported  a  series  of  30  cases 
in  which  the  use  of  this  apparatus  has  proved  very  eificient.  It  should  be 
employed  in  cases  of  older  persons,  or  which  have  been  long  resistant,  since  the 
ordinary  methods  of  manipulation  are  entirely  satisfactory  in  the  milder  forms. 


*  "Jour,  of  Med.  Research,"  Dec,  1903,  p.  440. 


872 


ORTHOPEDIC  SURGERY. 


The  gradual  reduction  of  the  dislocation  by  mechanical  means  is  still 
emploj'ed  by  some  surgeons,  the  apparatus  of  Schede  representing  the 
mechanical  principles  of  this  method. 

Operative  Methods  Other  Than  Bloodless. — In  subjects  which  are 
not  suitable  for  the  bloodless  reduction  certain  surgical  operations  are  of  value. 
These  include  the  following: 

I.  Tenotomy  of  the  adductors. 


^Pr^  ^B 

■1 

■j^H 

^7'             ^M 

Hr^ 

^^^^^H^j^l 

Pny 

^^^3 

'^W 

^V^f^t^HV 

% 

SijD- 

^m 

*"  j^ 

Fig.  676. — Same  as  Fig.  674;  Reduciiox  mxH  Widexixg  of  Acet.\bulum. 


2.  Resection  or  decapitation  of  the  femur. 

3.  Formation  of  a  new  articular  cavity,  or  arthrotomy. 

4.  Osteotomy. 

Tenotomy.  In  individuals  who  are  too  old  for  the  bloodless  reduction 
great  benefit  may  often  be  derived  from  the  free  division  of  the  adductor  muscles 
and  the  use  of  a  very  long  corset.  Acting  under  the  personal  suggestion  of 
Lorenz,  the  writer  has  employed  this  method  with  great  satisfaction  in  patients 
over  fifteen  years  of  age,  and  considers  it  in  many  ways  superior  to  the  more 


CONGENITAL  DISLOCATION  OF  THE  HIP.  873 

serious  operations.     It  improves  not  only  the  position  of  the  femur  but  reduces 
greatly  the  lordosis. 

Resection  or  decapitation  of  the  femur.  The  resection  of  the  femur 
for  the  relief  of  this  deformity,  while  it  has  been  performed  a  number  of  times 
in  the  past,  would  not  at  the  present  time  be  considered,  since  the  other  methods 
are  so  much  more  satisfactory.  The  operation  of  decapitation  of  the  femur 
in  itself  is  not  at  the  present  time  considered  by  surgeons  except  in  adult  cases. 


Fig.  677. — Same  as  Fig.  674;  Stretching  of  Capsule. 

Together  with  the  formation  of  a  new  articular  cavity  as  performed  by  Hoffa, 
this  operation  will  be  considered  in  detail  later. 

Arthrotomy ,  or  the  formation  of  a  new  articular  cavity.  The  method 
of  operation  as  formerly  performed  by  Hoffa  consisted  of  a  posterior  incision 
and  the  division  of  all  the  trochanteric  muscles.  This  extensive  operation  has 
since  been  replaced  by  the  more  simple  method  which  is  now  employed  by 
Hoffa. 

After  a  period  of  preparation,  about  two  weeks,  in  which  extension  has 
been  applied  to  the  limb,  and  in  certain  cases  the  adductors  forcibly  torn,  the 
operation  is  undertaken,  under  aseptic  precautions.     An  incision  six  inches  in 


874 


ORTHOPEDIC  SURGERY. 


length  is  made  on  the  inner  border  of  the  tensor  vaginas  femoris  at  the  junction 
of  the  middle  of  the  upper  third  of  the  thigh  and  is  carried  upward  to  the  anterior 
superior  border  of  the  great  trochanter.  The  fascia  lata  is  incised  and  the 
muscles  are  carefully  separated.  While  the  limb  is  held  in  abduction  a  sectional 
division  of  the  capsule  is  made  upon  its  anterior  surface,  in  the  direction  of  the 
insertion  of  the  femoral  head  into  the  pelvis.  If  this  incision  should  not  prove 
sufficient  to  permit  the  luxation  of  the  head  of  the  femur,  another  incision  may 
be  made  at  right  angles  to  the  first,  thus  making  a  T  incision.  A  new  cavity 
is  then  formed  by  excavating  the  old  cavity  by  means  of  a  Doyen  borer,  the 
excavation  being  deepest  at  its  upper  portion  so  as  to  prevent  the  slipping  of 


Fig.  678. — ScHEDE's  Extension  for  Dislocation  of  Hip. 


the  head.  The  femoral  head  is  then  put  into  place — a  matter  sometimes  difficult 
in  older  patients — by  the  retraction  of  the  capsule  to  its  anterior  surface,  and 
by  traction  and  abduction  of  the  limb,  the  traction  being  made  by  means  of 
windlass  and  folded  sheets.  The  wound  is  then  packed  with  a  tampon  of 
sterile  gauze,  and  antiseptic  dressing  is  applied  and  the  limb  fixed  by  the  appli- 
cation of  a  plaster  bandage,  while  the  assistants  make  a  contra-extension,  and 
traction  on  the  limb,  together  with  abduction  and  slight  inversion  of  the  foot. 
The  limbs  may  be  held  in  fixation  by  means  of  an  apparatus  described  by 
Hoffa  or  by  the  use  of  the  Phelps  bed.  The  patient  should  not  walk  until  the 
cicatrix  is  entirely  healed,  which  should  be  in  about  two  weeks'  time,  and  the 
cast  may  be  removed  at  the  end  of  three  weeks.     The  gauze  tampon  should  be 


CONGENITAL  DISLOCATION  OF  THE  HIP. 


875 


removed  in  about  eight  days  after  the  operation,  after  which  compresses  are 
appUed  to  either  side  of  the  wound,  and  the  dressing  of  the  wound  is  continued 
until  it  is  healed.  If  any  granulations  occur,  they  should  be  removed  by  the 
use  of  caustic  applications. 

During  a  certain  period  of  the  immobilization  of  the  hip  passive  move- 
ments are  given,  supplemented  by  massage. 

This  operation  presents  certain  grave  difficulties,  especially  when  performed 


Fig.  679. — HoFFA  Operation.     Incision  of  Capsule  (Berger  and  Banzet). 

E.I,  Poupart's  ligament;   i,  sartorius;  2,  long  head  of  biceps;  3,  tensor  vaginje  femoris;   Ca,  capsule;   C.F, 

neck  of  femur;  T.F,  head  of  femur. 


upon  older  patients,  exposing  them  to  the  dangers  of  absolute  or  relative  anky- 
losis, arrest  of  development,  and  contraction  of  the  pelvis.  There  is  usually 
a  certain  amount  of  shortening,  which  makes  it  particularly  unsuitable  for 
unilateral  cases,  and  although  there  have  frequently  been  very  excellent  results 
both  anatomically  and  functionally,  the  operation  has  been  abandoned  by  a 
great  number  of  orthopedic  surgeons. 

In  cases  where  neither  the  bloodless  reduction  nor  the  above  mentioned 


876 


ORTHOPEDIC  SURGERY. 


operation  are  suitable,  where  the  patients  are  over  ten  years  of  age,  or  in  bilateral 
cases,  another  operation  is  performed,  which  is  known  as  pseudo-arthrosis.  An 
incision  about  four  inches  in  length  is  made  over  and  above  the  trochanter, 
exposing  the  capsule;  the  joint  is  opened  and  the  head  of  the  bone  removed 
with  a  wide  chisel.  The  capsule  of  the  inner  surface  is  divided  longitudinally 
and  a  portion  removed  so  that  the  exposed  bone  will  fit  into  the  cavity.     The 


Fig.  6So. — Result  of-  Open  Operation  (Hofl 
Side  View. 


-S.\ME,  Back  View. 


adductors  are  divided  by  tenotomy.  The  wound  is  then  packed  with  a  tampon 
of  sterile  gauze,  aseptic  dressings  applied,  and  a  plaster  bandage  applied  to  fix 
the  limbs,  great  care  being  taken  to  keep  the  limbs  in  their  proper  relation  to 
each  other  so  that  there  is  no  change  in  the  angle  which  the  femur  makes  with 
the  pelvis  on  either  side.  Otherwise  it  would  be  necessary  subsequently  to  do 
an  osteotomy.  The  wounds  should  heal  in  about  three  weeks,  and  the  cast 
may  be  removed  at  the  end  of  six  weeks. 


CONGENITAL  DISLOCATION  OF  THE  KNEE.  877 

In  cases  of  patients  over  ten  years  of  age  this  operation  has  given  some 
very  good  results  both  anatomically  and  functionally,  the  patients  being  able 
after  recovery  from  the  operation  to  walk  from  five  to  ten  miles  without  dis- 
comfort. 

Osteotomy.  In  patients  over  ten  years  of  age  where  there  is  marked 
deformity  of  the  neck  of  the  femur,  and  particularly  in  unilateral  cases,  the 
operation  of  subtrochanteric  osteotomy  offers  the  best  chance  of  improving 
the  condition.  This  is  best  performed  by  exposing  the  trochanter  by  a  longi- 
tudinal incision  over  its  outer  border,  passing  retractors  about  its  circumference 
and  making  the  section  with  a  broad  chisel.  This  method  of  division  of  the 
bone  is  recommended  because  the  joint  is  movable  and  there  is  great  difficulty 
experienced  in  dividing  the  trochanter  under  these  circumstances.  It  is  quite 
easy  to  divide  the  trochanter  where  there  is  ankylosis,  as  in  ankylosis  of  the 
hip  from  hip-joint  disease.  If  the  deformity  of  the  neck  amounts  to  coxa  vara, 
a  small  wedge-shaped  section  may  be  removed  from  the  trochanter  and  the 
limb  dressed  in  a  position  of  forced  abduction,  as  has  been  recommended  in 
the  section  on  coxa  vara.  An  operation  of  this  character  improves  the  position 
of  the  neck  of  the  femur  without  the  danger  of  ankylosis. 


Congenital  Dislocation  of  the  Knee. 

This  condition,  which  is  an  exaggeration  of  congenital  genu  recurvatum, 
or  back-knee,  is  comparatively  rare.  Of  ii  observations  made  by  Hibbon, 
8  were  normal  in  other  respects  and  3  were  connected  with  other  malformations, 
the  former  presenting  unilateral  and  the  latter  bilateral  dislocations.  Keating 
mentions  49  cases  collected  from  other  writers,  including  dislocations  of  both 
sorts,  to  which  Lovett  has  added  three  personal  experiences  and  the  writer  two. 
Of  34  cases  reported  by  Taylor;  the  deformity  was  bilateral  in  18  and  unilateral 
in  16.  Twenty-four  cases  were  reported  as  anterior,  and  of  these,  in  one-half 
of  the  instances  no  patella  could  be  felt  at  birth.  Posterior  dislocation  is  very 
rare.  The  condition  is  often  found  to  follow  breech  presentations,  although 
neither  of  the  writer's  cases  were  of  this  character. 

Lateral  mobility  is  the  exception  and,  as  a  rule,  is  confined  to  bilateral 
cases  where  other  deformities  exist.  In  the  writer's  two  cases  there  was  no 
lateral  mobility.  Abduction  with  eversion  is  the  direction  in  which  mobility 
is  most  marked.  In  a  case  reported  by  Kronlein  there  was  ankylosis  with 
anterior  luxation  of  both  tibias.  The  cause  is  to  be  sought  in  some  malposition 


878 


ORTHOPEDIC  SURGERY. 


in  intrauterine  life  or  in  some  injury  sustained  at  birth.     Pathologically  the  con- 
dyle may  be  small  or  flattened,  the  patella  rudimentally  or  entirely  absent.     A  case 


Fig.  682. — Bilateral  Congenital  Dislocation  of  Knees. 


Fig.   683. — Unilateral  ^Congenital   Luxation  of 
Left  Tibia  (Army  Medical  Museum). 


Fig.  6S4. — Same,  showing  Result  of  Manual 
Reduction. 


of  Albert's  showed  the  vessels  lying  behind  the  outer  condyle  of  the  femur,  and  a 
bilateral  case  of  Wolff's  showed  the  luxation  of  one  knee  only  to  be  permanent. 


CONGENITAL  DISLOCATION  OF  THE  SHOULDER.  879 

The  treatment  of  congenital  dislocation  of  the  knee  can  generally  be  suc- 
cessfully accomplished  by  manipulation  and  the  use  of  braces.  In  the  writer's 
opinion  the  best  mode  of  treatment  is  the  use  of  plaster-of-Paris  casts,  changing 
them  from  time  to  time  as  the  correction  of  the  affected  part  advances. 

In  a  case  of  the  posterior  variety  reported  by  Hamilton  the  hamstrings 
were  divided  and  reduction  made.  A  simUar  instance  is  reported  by  Sayre  in 
Mason's  case. 

In  the  case  of  forward  dislocation  operation  is  seldom  desirable.  The 
writer  would  suggest  subcutaneous  division  of  the  rectus  tendon.  Wolff  gives 
an  instance  of  having  operated  for  forward  dislocation,  and  manual  osteoclasis 
of  the  lower  end  of  the  femur  has  been  reported  by  Phocas.  Taylor  reported 
a  case  which  showed  good  results  from  braces  worn  three  years. 

Congenital  Dislocation  of  the  Shoulder. 

The  rarity  of  congenital  dislocation  of  the  shoulder  is  shown  by  the  statistics 
of  Kronlein  from  Langenbeck's  clinic.  His  report  included  ninety-eight  cases 
of  various  congenital  dislocations,  and  of  these,  only  five  were  of  the  shoulder. 
In  the  majority  of  cases  the  position  of  the  head  is  usually  subspinous;  it  may, 
however,  be  supra-acromial  or  subcoracoid.  In  the  subspinous  cases  the  head 
of  the  humerus  is  just  posterior  to  the  normal  situation  of  the  glenoid  fossa, 
below  the  junction  of  the  acromion  process  with  the  spine  of  the  scapula. 

Under  the  term  congenital  dislocation  may  be  included  displacements  due 
to  the  following  causes:  (i)  Anatomic  changes  either  in  the  head  of  the  humerus 
or  the  glenoid  cavity  of  the  scapula.  In  this  class  there  may  be  other  congenital 
deformities,  the  lesion  may  be  double,  or  there  may  be  marked  shortening  in 
all  the  bones  of  the  extremity.  (2)  The  dislocation  may  be  caused  by  a  lax 
condition  of  the  capsule  as  a  result  of  paralysis.  In  these  cases  there  is  no 
deformity  of  the  bony  structures  and  the  dislocation  may  have  taken  place 
during  labor  or  at  a  previous  time.  (3)  The  dislocation  may  be  due  to  violence 
during  delivery.     In  this  class  the  articular  structures  are  normal. 

Symptoms. — In  most  cases  the  condition  is  not  recognized  for  some  time 
after  birth.  As  the  great  majority  are  of  the  subspinous  variety,  the  arm  is 
usually  abducted  and  rotated  inward,  while  the  head  of  the  bone  is  felt  in  its 
abnormal  position.  There  is  generally  limitation  of  motion  and  atrophy  of 
the  muscles  above  the  shoulder.  In  the  class  of  cases  that  may  be  considered 
purely  congenital  Porter  states  that  there  was,  without  the  slightest  doubt,  a 


S80  ORTHOPEDIC  SURGERY. 

difference  in  the  measurements  between  all  the  bones  of  the  affected  extremities 
in  his  cases.  He  is  upheld  in  this  statement  by  Scudder  and  Stimpson.  There 
is  usually  inability  to  put  the  hand  to  the  mouth,  and  in  some  cases  it  is  impos- 
sible to  carry  the  hand  forward  and  turn  it  over. 

Phelps  found  in  all  his  cases  a  fracture  of  the  posterior  border  of  the  glenoid 
cavity.  In  several  the  posterior  rim  of  the  glenoid  cavity  had  been  carried 
backward,  but  was  still  attached  to  the  capsule.  In  all  the  cases  the  glenoid 
cavity  was  semilunar  in  shape. 

Diagnosis. — The  two  forms,  the  one  due  to  imperfect  development  and 
the  traumatic  variety,  are  very  often  hard  to  differentiate  unless  the  joint  is 
opened.  This  is  especially  so  as  it  is  difficult  to  palpate  the  deep  structures  of 
the  joint  with  sufficient  accuracy  to  determine  the  form.  In  those  due  to  im- 
perfect development  of  the  articular  structures  there  coexists  a  similar  lack  of 
development  in  aU  the  parts  of  the  extremity,  as  pointed  out  by  Scudder  and 
Porter.  The  condition  is  often  confused  with  obstetric  paralysis.  They  re- 
remble  each  other  only  in  the  position  in  which  the  extremity  is  held.  In 
obstetric  paralysis  careful  examination  will  show  the  absence  of  a  dislocation. 
Separation  of  the  epiphysis  of  the  humerus  occurring  during  delivery  may 
resemble  dislocation,  but  will  be  readily  recognized  by  the  :x;-ray  examination. 

Many  cases  of  so-called  obstetric  paralysis  are  originally  dislocations  which 
have  remained  unreduced.  Continued  pressure  of  the  head  of  the  humerus 
on  the  brachial  plexus  in  cases  of  congenital  dislocation  in  time  produces  a 
paralysis,  which,  combined  with  the  deformity  present  in  dislocation,  often 
gives  the  picture  of  obstetric  paralysis.  The  author  has  recently  reduced  one 
of  these  dislocations  eight  months  after  birth,  with  perfect  restoration  of  function. 

Treatment. — This  consists  in  reduction,  if  possible,  as  soon  as  seen.  Dif- 
ferent methods  must  be  used  in  treating  the  form  due  to  imperfect  development 
and  that  due  to  traumatism.  In  those  cases  due  to  imperfect  development  the 
best  results  are  offered  by  an  early  operation  before  the  changes  in  the  glenoid 
cavity  have  taken  place.  A  number  of  cases  have  been  reported  but  no  treat- 
ment offered.  In  the  traumatic  variety  treatment  is  followed  by  good  results. 
In  these  cases  either  bloodless  reduction  or  operative  interference  may  be  used. 
WTiitman  suggests  that  treatment  similar  to  that  used  in  congenital  displace- 
ments of  the  hip  is  successful.  He  has  been  able  by  means  of  prolonged  forcible 
manual  stretching  to  relax  the  contracted  parts  sufficiently  to  reduce  two  cases 
by  manipulation.  The  parts  then  are  to  be  placed  in  plaster-of-Paris  for  several 
months.     The  limb  should  be  extended  on  the  scapula,  thus  forcing  the  head 


CONGENITAL  DISLOCATION  OF  THE  ELBOW.  881 

of  the  humerus  into  its  proper  place,  and  it  should  be  rotated  outward  to  over- 
come the  inward  rotation.  The  parts  should  be  fixed  for  several  months,  after 
which  massage,  passive  motion,  and  electricity  may  be  instituted.  In  case  of 
recurrence  the  joint  may  be  opened  and  attempts  made  to  bring  the  parts 
together,  or  the  articulating  cartilages  may  be  removed  in  the  hope  of  obtaining 
ankylosis. 

Phelps  has  seen  eight  cases  of  congenital  dislocation  of  the  shoulder ;  four 
of  them  were  operated  on,  and  the  other  four  were  reduced  under  anesthesia. 
In  three  of  the  operated  cases  the  deformity  has  recurred;  in  the  fourth  the 
head  of  the  humerus  was  in  a  better  position  and  there  was  fifteen  to  twenty 
degrees  of  passive  motion  possible.  Of  the  four  reduced  under  anesthesia,  all 
were  under  one  year  of  age  and  had  done  well.  In  one  of  Phelps'  cases  he 
opened  the  joint  by  a  posterior  incision  along  the  border  of  the  deltoid  muscle,  and 
found  the  atrophy  of  the  scapula  and  a  portion  of  the  edge  of  the  glenoid  cavity 
broken  away.  There  was  marked  contraction  of  the  structures  on  the  anterior 
aspect  of  the  joint,  compelling  him  to  cut  away  a  portion  of  the  head  of  the 
humerus  to  reduce  the  dislocation.  The  false  cavity  and  a  portion  of  the  capsule 
were  also  removed.     He  states  that  the  result  was  very  good. 

At  present  our  knowledge  of  the  pathology  and  causation  of  the  condition 
is  not  sufficient  to  establish  a  successful  method  of  treatment. 

Porter  reviews  the  literature  of  the  subject  and  the  reports  on  twenty-nine 
cases.  The  results  of  treatment  are  for  the  most  part  unsatisfactory,  recurrence 
being  frequent. 


Congenital  Dislocations  of  the  Elbow. 

Congenital  dislocations  of  the  ulna  and  radius  are  very  rare,  and  while 
some  cases  have  been  reported  they  are  for  the  most  part  of  little  practical 
importance.  They  may  be  due  to  a  lax  condition  of  the  ligaments,  to  imperfect 
development  of  the  condyles  or  coronoid  or  olecranon  processes,  to  lack  of 
development  of  the  radial  articulation  of  the  humerus,  the  head  of  the  radius 
or  articular  cartUage.  The  condition  is  at  times  accompanied  by  other  con- 
genital malformations,  and  is  often  bilateral.  Ronnenberg  collected  31  cases 
from  the  literature  of  the  subject,  and  in  a  number  he  found  a  history  of  heredity. 
The  radius  is  most  frequently  dislocated,  and  in  some  instances  there  is  also  a 
dislocation  of  the  ulna. 

The  dislocations  may  be  divided  into  the  following  classes:    (i)  Dislocation 


882  ORTHOPEDIC  SURGERY. 

of  both  radius  and  ulna  backward;  (2)  dislocation  of  the  radius  forward  and 
upward ;  (3)  complete  dislocation  of  the  radius  backward  with  partial  dislocation 
of  the  ulna  backward.  In  this  class  the  coronoid  process  or  the  external  condyle 
is  usually  undeveloped. 

Very  often  the  condition  is  not  accompanied  by  any  disability.  At  times 
supination  is  diminished  on  account  of  the  comparative  length  of  the  radius. 
In  most  cases  there  are  no  subjective  symptoms.  In  dislocation  of  the  radius 
causing  disability  benefit  may  be  obtained  by  resection  of  the  head  of  the  radius. 
Most  cases,  however,  require  no  treatment. 


CHAPTER  XXX. 

PERVERTED  DEVELOPMENT. 

The  number  of  congenital  deformities  dependent  upon  perverted  develop- 
ment is  very  large,  but  some  of  these  have  been  omitted  altogether;  others 
belong  more  properly  to  works  upon  teratology,  and  only  three  need  here  be 
described — club-hand,  deformities  of  fingers  and  toes,  and  deficiency  of  parts. 

Club-hand. 

Club-hand  includes  any  deviation  of  the  hand  from  its  normal  relation  to 
the  forearm  at  the  wrist. 

Synonjrms. — French,  Main-bote.     German,  Klumphand. 

The  deformity  may  be  in  the  direction  of — (i)  flexion,  or  palmar,  (2) 
extension,  or  dorsal,  (3)  adduction,  or  radial,  (4)  abduction,  ulnar  or  cubital, 
or  any  combination  of  these,  as  radio-palmar,  radio-dorsal,  cubito-palmar,  and 
cubito-dorsal. 

The  affection  is  generally  congenital,  but  may  be  acquired.  One  or  both 
hands  may  be  affected. 

The  flexion  forms  are  most  common,  and  the  deformity  is  usually  associated 
with  other  malformations. 

The  congenital  varieties  occur  in  all  four  forms,  the  flexion  and  extension 
being  most  common  without  the  absence  of  bones,  and  the  lateral  deformities 
being  usually  associated  with  an  absence  of  the  radius  or  ulna.  The  adduction 
or  radial  form  is  most  common,  in  which  respect  it  corresponds  to  the  greater 
frequency  of  congenital  absence  of  the  fibula.  Of  the  cases  reported  by  Hoffa, 
thirty-nine  were  radial  and  six  were  ulnar. 

Etiology. — The  cause  is  obscure,  but  may  be  accounted  for  in  congenital 
cases  by  the  pressure  theory  of  absence  or  deficiency  of  liquor  amnii,  and  where 
there  is  associated  deficiency  of  bones,  by  the  theory  of  attachment  of  the  amnion 
to  the  skin  while  these  parts  were  in  contact  in  early  embryologic  life.  A  rare 
cause  from  cerebral  injury  has  been  reported  by  the  writer.  The  acquired 
variety  may  result  from  nerve  irritation  from  bullets,  tumors,  bone,  or  as  sequels 
of  burns  and  scalds. 

883 


884  ORTHOPEDIC  SURGERY. 

Symptoms. — The  hand  is  not  rigidly  held  in  the  deformed  position,  but 
admits  of  a  certain  range  of  motion,  beyond  which  it  is  checked  by  the  shortened 
muscles  or  bony  changes.  The  diagnosis  is  made  upon  inspection.  In  all 
cases  where  it  is  possible  a  skiagraph  of  the  deformity  should  be  taken,  as  it 
is  often  impossible  to  determine  the  exact  amount  of  bony  deficiency  without 
this  aid.     The  possibilities  of  recovery  without  treatment  are  slight. 

Treatment. — In  mild  congenital  cases  manipulation  and  the  use  of  a 
pressure  bandage  will  accomplish  a  cure,  as  in  the  case  reported  by  Piechaud, 
of  a  child  with  double  club-hand  of  the  ulnar  variety,  cured  by  the  mother's 
manipulation  in  five  months. 

Plaster-of-Paris  bandages  have  been  successfully  employed.  In  the  severer 
forms  tenotomy  will  be  indicated,  the  tendons  requiring  division  being  generally 
the  palmaris  longus,  flexor  carpi  ulnaris,  and  flexor  carpi  radialis.  The  possi- 
bilities of  ununited  tendon  after  tenotomy  are  greater  in  this  region  than  else- 
where, and  in  most  cases  where  practicable  the  tendon  should  be  lengthened 
by  the  modern  method  of  open  incision,  identical  with  Willett's  operation  in 
the  foot.  An  operation  of  this  character  upon  a  young  woman  suffering  from 
monoplegia  by  the  writer  proved  eminently  successful. 

In  cases  due  to  severe  irritation  the  removal  of  the  cause  will  accomplish 
a  cure,  and  in  paralytic  cases  the  use  of  suitable  mechanical  appliances  should 
be  assisted  by  massage  and  electricity.  Where  there  is  congenital  absence  of 
the  epiphysis  of  the  radius  or  ulna,  an  attempt  may  be  made  to  correct  the 
deformity  by  excision  of  the  epiphysis  which  is  normal  in  order  to  destroy  the 
growth  of  the  part. 

Operations  on  the  bones  are  sometimes  undertaken  for  the  correction  of 
club-hand.  Bardenheuer  split  the  distal  end  of  the  ulna  longitudinally  and 
fixed  the  ends  to  the  carpal  bones  with  an  ivory  peg  upon  each  side.  The 
result  was  reported  good.  Subsequently  McCurdy  obtained  a  good  result  in 
a  case  of  palmar  club-hand  by  dividing  the  ulnar  bone.  Through  an  oblique 
incision  across  the  forearm  the  ulna  was  divided  so  that  the  upper  fragment 
was  brought  into  contact  with  the  semilunar  bone,  to  which  it  was  sutured. 

Deformities  of  the  Fingers  and  Toes. 

The  congenital  deformities  of  the  fingers  consist  of  six  classes:  super- 
numerary fingers  and  toes,  congenital  deficiencies,  congenital  union,  h}'per- 
trophy,  deviations,  contraction,  and  tumors. 

Supernumerary  fingers  and  toes,  bioA^m  also  as  polydactylism ,  is  not  an 


PERVERTED  DEVELOPMENT.  885 

uncommon  inheritance  in  some  families.  It  may  recur  in  every  generation, 
or  one  or  more  generations  may  escape  this  deformity.  It  may  be  unilateral, 
but  as  a  rule  is  bilateral,  there  being  usually  one  additional  member  on  each 
hand  and  foot.  This  number  may  be  greatly  exceeded,  as  in  the  cases  of 
Saviard  and  Voigt,  which  had  respectively  ten  and  thirteen  fingers  and  toes  on 
each  hand  and  foot,  or  the  case  of  Bradford  and  Lovett,  which  had  fifteen 
fingers  and  ten  toes.  The  additional  parts  are  usually  added  upon  the  ulnar 
side  of  the  hand.  Some  are  fully  formed,  but  more  often  they  are  imperfect 
and  associated  with  other  deformity,  especially  congenital  union. 

The  proper  treatment  consists  in  the  removal  of  the  supernumerary  parts, 
and  this  can  be  accomplished  with  perfect  safety  at  two  or  three  months  after 
birth.     In  exceptional  cases  the  amputated  part  may  be  perfectly  reproduced, 


Fig.  685. — Lobster  Claw  Deformity  of  Hand. 

as  in  the  remarkable  case  of  White,*  where  a  supernumerary  thumb  was  twice 
entirely  reproduced. 

Congenital  deficiencies,  or  ectrodactylisms,  either  in  the  number  or 
bulk  of  digits,  are  not  common,  and  when  they  do  occur  are  usually  the  result 
of  amniotic  inflammatory  adhesion  or  amputation,  not  hereditary,  but  the  result 
of  maternal  impression.     All  the  fingers  of  one  or  both  hands  may  be  wanting. 

Lobster-claw. — A  peculiar  absence  of  the  fijigers  with  deformity  has  been 
described  by  Tubby,  Emil  Haim,  and  others,  and  from  its  resemblance  to  the 
claw  of  a  lobster  it  has  been  distinguished  as  the  "lobster-claw"  deformity — 
the  spaltfuss  and  spalthand  of  the  Germans.  During  the  winter  of  1904-1905  I 
had  an  opportunity  of  studying  a  family  affected  in  this  manner  who  were 
residing  in  Philadelphia.     It  is  usually  a  hereditary  affection,  the  case  described 

*  C.  White  :  "On  the  Regeneration  of  Animal  Substances." 


886  ORTHOPEDIC  SURGERY. 

by  Tubby  having  been  traced  through  the  family  for  several  generations.  All 
of  the  members  of  the  family  presented  abnormalities  of  hands  and  feet.  The 
deformities  in  families  so  afflicted  are  not  always  uniform.  In  the  family  which 
came  under  my  observation  the  cases  appeared  to  have  been  sporadic,  the 
ancestors  not  being  affected.  Of  the  immediate  family,  the  first  two  children 
were  normal,  the  third  deformed,  the  fourth  normal,  and  the  two  succeeding 


Fig.  686. — Velpeau  Operation. 
Dorsal  flap  brought  through  between  fingers  and 
stretched    on    the   palmar   side;    also   wound 
closed  on  opposite  side  of  fingers  (Agnew). 


Fig.  687. — Form  of  Incision  for  Webbed  Fin- 
gers IN  Velpeau  Operation  (Agnew). 


Fig.  688. — Didoi's  Operation  for  Syndac- 
tylism, Represented  in  Cross-section 
(Bradford  and  Lovett). 


Fig.  6Sg. — Didot's    Operation   for   SYNDACT-ixiSM 

(Bradford  and  Lovett). 

A,  B,  Dorsal  flap;  C,  D,  palmar  flap. 


ones  deformed.     In  Haim's  case  the  grandfather,  the  mother,  and  the  child  were 
all  similarly  affected. 

The  deformity  consists  in  the  absence  or  suppression  of  the  second,  third, 
and  fourth  fingers,  the  thumb  usually  being  longer  than  normal  and  hyper- 
trophied,  and  the  little  finger  is  also  apt  to  be  over-developed.  Between  the 
thumb  and  the  little  finger  there  is  a  wide  gap  from  the  loss  of  the  fingers  and 
metacarpal  bones.     The  carpal  and  dorsal  bones  are  usually  present,  as  shown 


PERVERTED  DEVELOPMENT. 


887 


by  the  skiagraph,  and  the  metacarpal  bone  may  be  bifurcated  or  may  be  deviated 
laterally,  and  the  bifurcation  may  be  marked  by  an  exostosis.     Males  appear 


Fig.  690. — Dissection  of  the  Dorsal  Strip  of 
Skin.  Operation  of  Forgue  foe  Webbed 
Fingers. 


Fig.  691. — Application  of  the  Dorsal  Strip  to 
the  Internal  and  Palmar  Surfaces  of  the 
Middle  Finger. 


Fig.  692. — Dissection  of  a  Strip  to  Re-cover 
the  External  and  Dorsal  Surfaces  of  the 
Third  Finger.  Forgue  Operation  for 
Syndactylism. 


Fig.  693. — Result  of  the  Operation. 


to  be  more  frequently  affected  than  females  and  the  deformity  appears,  as  a 
rule,  to  be  transmitted  through  the  males. 

The  lobster-claw  deformity  sometimes  exists  in  the  foot,  the  second,  third, 


ORTHOPEDIC  SURGERY. 


and  fourth  toes  being  absent,  the  great  toe  and  httle  toes  being  over-developed, 
as  in  the  hand.  When  the  deformity  is  very  severe,  it  interferes  with  locomotion, 
but  where  it  is  not  severe  the  shoe  conceals  it,  and  if  there  is  no  similar  affection 
of  the  hands  it  passes  unnoticed. 

The  treatment  is  limited  to  the  separation  of  webbed  fingers,  or  plastic 
operations  to  restore  deficient  parts. 

Congenital  union,  or  webbed  fingers  and  toes,  scientifically  known  as 
syndactylism ,  is  common,  and  may  involve  the  union  of  the  digits  throughout 
their  whole  length  or  only  the  terminal  phalanges. 

The  united  parts  may  be  divided  by 
a  simple  incision,  and  the  parts  held  apart 
by  strips  of  oiled  lint  until  cicatrization  is 
complete,  but  the  plastic   operations  of 


Fig.  694. — Congenital  Hypertrophy  of 
Fingers  (Morton). 


Fig.  695. — Congenital  Hypertrophy  of  Fingers 
(Jones). 


Velpeau  or  Didot  or  Forgue  are  more  satisfactory.  Velpeau's  operation 
consists  of  a  V-shaped  flap  cut  from  the  dorsal  surface  of  the  base  of  the  web, 
with  the  apex  anterior,  extending  through  one-half  of  the  thickness  of  the  band. 
This  flap  is  dissected  back,  the  remaining  portions  of  the  web  slit  longitudinally, 
the  flap  drawn  through  the  cleft  at  the  base  of  the  fingers,  its  apex  stitched  to 
the  palmar  surface  of  the  wound,  and  its  sides  to  the  sides  of  the  fingers. 

Didot's  operation  consists  of  a  palmar  flap  from  one  finger  and  a  dorsal 
flap  from  the  adjoining  one,  the  flaps  extending  to  the  middle  of  the  fingers. 
The  remaining  web  is  divided  and  the  dorsal  flap  of  one  covers  the  palmar 


Fig.  696. — Skiagraph  of  Hypertrophy  of  Finger  (Jones). 


PERVERTED  DEVELOPMENT. 


891 


surface  of  the  other.  Separation  of  webbed  toes  is  not  so  often  demanded, 
since  the  deformity  is  easily  concealed,  but  when  necessary  it  should  be  per- 
formed by  the  same  methods  as  for  webbed  fingers. 

Forgue  has  modified  the  operation  of  Velpeau  by  dissecting  a  flap  from 
the  dorsum  of  the  hand,  with  the  base  toward  the  finger,  over  the  metacarpal 
bone  of  the  denuded  finger,  and  suturing  it  to  the  external  and  dorsal  surfaces 
of  the  denuded  finger. 

Hypertrophy  of  the  fingers  and  toes  usually  affects  but  one  or  two 
digits.  Some  of  the  cases  formerly  classed  under  this  head  belong  more  properly 
vmder  akromegaly.     Sometimes  the  hypertrophy  of  the  fingers  and  toes  is  com- 


FiG.  697. — Congenital  Hypertrophy  of  Toes  (Shoemaker). 


posed  of  the  soft  parts  only,  but  in  others  there  is  present  a  hypertrophy  of  the 
osseous  structures  as  well.     The  treatment  demanded  is  amputation. 

Congenital  contraction  of  the  fingers  and  toes  is,  in  some  cases,  hered- 
itary, and  is  usually  the  result  of  defect  or  deficiency  of  the  bones  or  contracture 
of  the  fascias  and  muscles. 

The  contractions  of  the  toes  have  already  been  described,  and  there  remain 
only  the  congenital  contraction  of  the  finger,  the  contraction  of  the  palmar 
fascia,  or  Dupuytren's  contraction,  trigger-finger,  and  mallet-finger. 

Congenital  Contraction  of  the  Fingers. — This  affection  consists  of  a 
contraction  of  the  little  finger,  and  sometimes  the  ring-finger,    and   in    very 


892  ORTHOPEDIC  SURGERY. 

exceptional  instances  all  of  the  fingers  may  be  contracted.  This  deformity  is 
hereditary,  and  differs  from  Dupuytren's  contraction  in  that  the  contraction 
is  limited  to  the  fascias  and  tendons  of  the  finger  and  does  not  involve  the  palmar 
fascia.  Three  stages  have  been  described — the  mild,  medium,  and  severe  forms. 
In  the  severe  form  a  thickened  fascia  may  be  felt  on  the  palmar  surface  of  the 
fingers.  The  treatment  consists  in  the  manipulation  of  the  part  in  mild  cases 
and  in  division  of  the  fascias  in  severe  cases. 

Dupuytren's  Contraction.  Synonyms: — French,  La  Contraction  des 
Doigts;  La  Maladie  de  Dupuytren.  German,  Die  Dupuytren'sche  Kontrak- 
tur  der  Finger. 

Dupuytren's  contraction  is  a  name  applied  to  a  contraction  of  the  palmar 
fascia  or  its  digital  prolongation  producing  permanent  flexion  of  one  or  more 
of  the  fingers.  This  condition  had  been  described  prior  to  Dupuytren,  but 
he  was  the  first  to  demonstrate  clearly  its  pathology  by  careful  dissection  of 
a  hand  he  was  fortunate  enough  to  possess. 

The  cause  of  this  disease  has  never  been  satisfactorily  explained.  Two 
theories  account  for  the  major  part  of  the  cases — the  influence  of  long-continued 
slight  traumatism,  and  of  a  rheumatic  or  gouty  diathesis.  Syphilis  is  undoubt- 
edly an  occasional  factor  in  the  causation,  and  recently  Abbe  has  advanced  a 
theory  of  central  nervous  irritation  producing  nutritive  changes  in  the  affected 
hand. 

In  Keen's  recorded  seventy-two  cases,  only  eighteen  were  among  the  laboring 
classes.  This,  together  with  the  fact  that  the  left  hand  is  as  frequently  involved 
as  the  right,  and  that  the  ring  and  little  fingers  are  most  commonly  affected, 
while  certainly  they  are  not  the  most  exposed,  sufficiently  explodes  the  theory 
of  traumatism.  On  the  other  hand,  there  are  few  American  families  in  Avhom 
it  is  not  possible  to  find  a  rheumatic  member. 

The  deformity  is  caused  by  a  scar-like  contraction  of  the  palmar  fascia 
and  the  areolar  network  overlying  it,  by  means  of  which  the  digital  prolongations 
of  the  fascia  are  retracted  and  the  fingers  flexed  into  the  palm.  The  tendons 
lying  below  the  fascia  remain  free  and  uninvolved.  Along  the  course  of  the 
contraction  small  hard  bodies  are  found,  which  upon  examination  prove  to 
be  small  fibromas.     The  skin,  if  affected  at  all,  is  only  so  late  in  the  disease. 

The  first  sign  is  a  small  body,  the  size  of  a  shot,  appearing  in  the  metacarpal 
phalangeal  crease,  with  some  stiffness  of  the  ring  or  little  finger.  This  is  entirel}- 
painless.  After  some  months  or  3'ears  a  cord  is  noticed  running  to  these  fingers, 
which  are  contracting  into  the  palm. 


PERVERTED  DEVELOPMENT.  893 

The  forced  flexion  of  the  fingers,  the  fact  that  ankylosis  of  the  joints  does 
not  exist,  the  absence  of  pain,  the  advanced  age  of  the  patient,  the  non-existence 
of  cerebral  or  spinal  disease,  or  of  injury  to  the  part,  with  loss  of  substance  fol- 
lowed by  a  scar-like  contraction,  present  so  clear  a  clinical  picture  that  the 
diagnosis  cannot  easily  be  mistaken. 

The  only  condition  from  which  this  deformity  should  be  distinguished  is 
congenital  contraction  of  the  fingers.  From  this  condition  it  differs  in  the  fol- 
lowing points:  Congenital  contraction  of  the  fingers  occurs  in  early  life,  whereas 
Dupuytren's  contraction  occurs  in  late  life.  Congenital  contraction  is  more 
frequent  in  females,  while  Dupuytren's  contraction  is  more  frequent  in  males. 
In  congenital  contraction  the  fascias  of  the  fingers  only  are  involved,  and  in 
Dupuytren's  contraction  the  palmar  fascia  only  is  involved.  In  congenital  con- 
traction the  first  phalanx  is  hyperextended  while  the  second  and  third  are  flexed, 
and  in  Dupuytren's  contraction  the  third  is  generally  hyperextended  while  the 
first  and  third  are  flexed. 

An  absolutely  favorable  prognosis  can  be  given  if  an  operation  is  allowed. 
The  condition  is  not  easily  corrected  without  it. 

The  medicinal  treatment  is  nil  except  when  there  is  a  syphUitic  taint, 
when  iodids  should  be  freely  used  with  prospects  of  cure,  as  in  the  successful 
cases  recorded  by  Richet  and  Ricord.  The  mechanical  treatment  has  been 
abandoned  for  the  surgical,  which  consists  of  either  a  subcutaneous  incision  of 
the  fibrous  bands,  or  an  open  one,  with  or  without  removal  of  part  of  the  con- 
tracting tissue.  A  small  pointed  tenotome  should  be  inserted  a  little  to  one 
side  of  the  cord  and  the  fascia  cut  down  upon.  This  is  repeated  in  several  places 
until  the  fingers  can  be  partially  straightened.  Dupuytren's  original  operation 
of  open  transverse  incision  through  the  band  in  its  two  or  three  most  prominent 
places  is  still  practised,  or  the  skin  may  be  reflected  in  a  V-shaped  flap  and 
the  contracting  material  dissected  out.  A  curved  splint  should  be  applied  for 
the  first  few  days,  after  which  time  it  may  be  replaced  by  a  straight  one,  to  be 
worn  for  two  or  three  weeks.  Ether  need  not  be  used,  cocain  anesthesia  (2  per 
cent,  solution)  being  sufficient. 

Trigger-finger. — {Synonyms,  Snap-,  jerk-,  or  spring-finger.)  Trigger- 
finger  consists  in  the  permanent  flexion  of  one  finger  when  the  others  are  ex- 
tended. The  contraction  of  the  finger  may  be  overcome  by  a  gi'eater  voluntary 
effort,  when  it  usually  flies  backward  suddenly  with  a  snap  to  the  extended 
position,  from  which  characteristic  it  has  derived  its  names.  The  thumb, 
middle,  and  ring  fingers  are  the  ones  most  frequently  affected.     The  cause  of 


894 


ORTHOPEDIC  SURGERY. 


the  affection  is  some  interference  with  the  free  motion  of  the  tendon  as  it  passes 
through  its  sheath  or  through  a  groove,  the  difficulty  being  due  either  to  an 
expansion  or  thickening  of  the  tendon  or  to  a  narrowing  of  the  groove.  Some- 
times the  obstruction  is  a  small,  hard,  rough  body  smaller  than  a  pea  and  at- 
tached to  the  deep  structures  in  the  vicinity  of  the  sheath  of  the  flexor  tendon 
of  the  thumb  or  index-finger.  Small  ganglia  have  also  been  discovered  upon 
the  flexor  tendons.  The  treatment  consists  in  the  excision  of  the  ganglion  if 
it  can  be  detected.  The  inflammation  of  the  fascia  requires  counter-irritation 
with  iodin  or  the  Paquelin  cautery. 


Fig.   698. — Dupuytilen's    Finger    Contraction 
(Ashhurst). 


Fig.  699. 


-The  S.\ue  H.\nd   apter  Operation 
(Ashiiurst). 


Mallet-finger. — [Synonym,  Drop-finger.)  This  deformity  consists  in  the 
flexion  of  one  finger  when  the  others  are  fully  extended,  and  is  usually  the  result 
of  injuries  received  in  athletic  sports,  and  is  caused  by  the  rupture  or  detach- 
ment of  the  fibers  of  the  ligament  on  the  posterior  surface  of  the  distal  phalangeal 
joint.  It  is  very  common  among  baseball-players.  The  injury  which  produces 
the  deformity  is  frequently  very  slight.  Immediately  foUoviong  the  injury  there  is 
sometimes  discoloration,  slight  swelling  over  the  last  joint,  with  a  tender  area  on 
the  posterior  surface  of  the  last  phalanx.  The  treatment  consists  in  fixing  the 
finger  in  fuU  extension  upon  a  metal  splint.  If  this  method  of  treatment  does 
not  effect  a  cure,  in  two  weeks  an  incision  should  be  made,  linear  in  character, 


PERVERTED  DEVELOPMENT.  895 

in  such  a  manner  as  to  expose  the  torn  fascicuH.  These  may  then  be  sutured 
into  the  skin  or  the  periosteum,  preferably  the  latter,  and  the  deformity  be 
slightly  over-corrected  and  the  finger  fixed  with  a  splint. 

Congenital  tumors   of  the  fingers  and  toes  have  been  grouped  by 


Fig.  700. — Skiagraph  or  Congenital  Tumor  of  Foot  (Spelliss)). 

Annandale  into  four  classes:    (i)  pedunculated  growths  or  excrescences  of  the 
skin,  (2)  fatty  growths,  (3)  fibrous  growths,  and  (4)  cartilaginous  growths. 

The  treatment  consists  in  removal  of  the  growths,  those  of  the  first  class 
being  removed  early,  and  those  of  the  other  groups  being  permitted  to  remain 
until  the  period  of  infancy  is  passed. 


896 


ORTHOPEDIC  SURGERY. 


Congenital  Deficiency  of  Parts. 

Congenital  deficiencies  vary  in  extent  from  the  absence  of  a  single  digit 
to  the  entire  lack  of  one  or  more  extremities.  They  may  be  classed  under  two 
heads:  Complete  or  partial  absence  of  the  part,  and  diminution  in  size,  the 
part  being  perfectly  formed.  The  total  absence  of  both  upper  and  lower 
extremities  is  an  exceedingly  rare  malformation.  In  all  the  systematic  works, 
upon  teratology  reference  is  made  to  this  deformity,  and  cases  have  been 
reported  by  Hare  and  Hardy.  Entire  absence  of  both  upper  extremities  has 
been  observed  by  a  number  of    surgeons,   and  the  v^riter  has  observed  two 


Fig.  701. — Congenital  Absence  of  Ulna.     Right  Arm  (Roberts). 


Fig.  702. — Congenital  Absence  of  Ulna.     Left  Arm  (Roberts). 

unrecorded  cases,  one  an  artist  familiar  to  many  for  his  reproductions  of 
paintings  in  the  modern  gallery  in  Antwerp,  Belgium,  _  and  the  other  an 
inmate  of  the  Philadelphia  Almshouse,  the  proud  father  of  a  large  family.  In 
such  cases  the  feet  acquire  great  tact  and  skUl  and  fulfil  the  offices  of  the  hands. 
Entire  absence  of  the  lower  extremities  is  very  rare  also,  and  the  accom- 
panying illustrations  of  Shoemaker's  case*  show  an  excellent  example  of  this 
type  (Figs.  705  and  706).  Partial  deficiencies  are  much  more  common,  and 
many  cases  of  this  character  are  recorded. 


*  "Trans.  Coll.  Phys.  Philadelphia,"  iSgs,  p.  191.     "Internal.  Med.  Mag.,"  March,  1893. 


Fig.    703. — Congenital   Absence   of   Carpal    and 
Metacarpal  Bones. 


Fig.  704. — CoNGENiT.AL  Deficiency  of  Hand. 


Fig.    705. — Congenital  Deficiency  of  Ex- 
tremities.    Sitting  Position  (Shoemaker). 


Fig.  706. — Congknital  Deficiency  of  Extrem- 
TIES.  Position  Assumed  when  Walking  on 
Hands. 


Fig.  707. — ."Vuthor's  Case  of  Double  Congenit.al  Absence  of  Tibia. 


PERVERTED  DEVELOPMENT. 


901 


Of  absence  of  the  humerus,  partial  or  complete,  no  cases  are  found  in 
literature,  but  of  all  the  other  bones  the  number  is  very  large.  Compared  with 
congenital  absence  of  the  ulna,  the  absence  of  the  radius  is  quite  common. 
Absence  or  defect  of  the  femur  has  been  observed  many  times,  and  Meyersohn 
has  collected  eighteen  cases  of  fibular  defect.  Con- 
genital absence  of  the  tibia  has  received  more  atten- 
tion and  study  than  any  other  similar  deformity, 
and  for  a  full  description  of  this  remarkable  mal- 
formation the  reader  is  referred  to  the  recent  mono- 
graph  of  the  writer,*  in  which  four  cases  are 


Fig.  708. — Single  Congenital  Absence  of  the  Tibia  (Ehrich). 


Fig.  yog. — Congenital   Defici- 
ency OF  Femur. 


recorded,   together    with   a   complete    bibliography   of    the    forty-eight   cases 
abstracted  from  literature. 

These  cases  attract  the  greatest  interest  from  an  orthopedic  standpoint  on 
account  of  the  associated  club-foot,  and  are  the  only  ones  demanding  extended 
description. 


*  "Univ.  Pa.  Med.  Bull.,"  Nov.,  1904. 


902 


ORTHOPEDIC  SURGERY. 


Etiology. — The  study  of  the  cause  of  congenital  absence  of  the  bones 
reveals  much  that  is  mysterious,  hypothetic,  and  unexplained,  from  the  fact 
that  no  pathologic  specimens  have  been  examined  which  exhibit  the  exact 
production  of  this  deformity.  Hence  numerous  theories  have  been  advanced 
from  time  to  time  to  account  for  the  deformity.  It  has  been  attributed  to 
heredity,  pre-natal  disease,  arrest  of 
development,  mechanical  pressure, 
and  to  amniotic  adhesions. 


-High  Shoe  for  Case  of  Congenital 
Deficiency  of  Femur. 


-jii. — CoxGExiTAL  Deficiency  of  Extremi- 
ties.    Per.m.anent  .\pparatus  .\pplied. 


It  is  now  generally  admitted  by  authorities  that  the  cause  of  congenital 
absence  of  parts  is  an  amniotic  adhesion.  The  occurrence  of  amniotitis  has 
been  doubted  by  some  authorities.  When  the  exact  mode  of  the  origin  of  the 
amnion  is  explained,  the  whole  subject  of  the  development  of  teratologic  anoma- 
lies will  be  illumined.  Enough  is  understood  to  explain  the  process  of  formation 
of  amniotic  bands  resulting  in  fetal  amputation,  adhesions  between  the  amnion 
and  fetal  parts,  and  to  indicate  that  inflammation  of  the  membrane  is  possible. 
The  contact  of  the  amnion  with  parts  of  the  fetus  results  in  adhesions,  whUe 
the  subsequent  increase  of  fluid  results  in  the  formation  of  bands,  cords,  or 
in  the  destruction  and  absorption  of  the  attached  parts. 


PERVERTED  DEVELOPMENT.  '  903 

After  the  attachment  of  the  part  to  the  amnion  the  inflammation  present 
produces  an  acute  polyhydramnios,  which,  making  traction  upon  the  attached 
portion  of  the  amnion,  pulls  the  skin  and  the  underlying  structures  from  their 
places,  separating  them  from  their  vascular  and  nervous  connections,  or,  by 
the  formation  of  amniotic  bands,  cutting  them  off  entirely  and  producing  their 
absorption. 

From  a  careful  examination  of  the  cases  coming  under  my  personal  ob- 
servation and  from  a  thorough  investigation  of  the  literature  upon  this  interesting 
subject  I  am  of  the  opinion  that  congenital  absence  of  the  bones  is  not  terato- 
genic but  that  it  is  due  to  amniotic  adhesions  resulting  from  traumatism,  slight 
in  character,  and  occurring  usually  about  the  third  month  of  fetal  life. 

In  reference  to  the  marked  club-foot  present  in  all  these  cases,  the  absence 
of  the  internal  condyle  and  the  unopposed  action  of  the  adductors  are  sufficient 
explanation,  to  my  mind,  for  this  deformity.  That  they  were  not  the  result 
of  deficiency  of  liquor  amnii  and  intrauterine  pressure  is  clearly  proved  by  the 
absence  of  pressure  marks  on  other  parts;  the  rare  association  of  club-hand, 
the  fact  that  no  appreciable  diminution  in  the  quantity  of  liquor  amnii  was 
observed  in  these  cases  over  previous  or  subsequent  labors,  but  more  particularly 
by  the  case  recently  observed  of  double  equino-varus  in  a  twin,  the  other  chUd 
showing  no  deformity  whatever. 

The  treatment  will  depend  on  the  degree  of  deformity  and  the  inconve- 
nience caused  by  it,  and  upon  the  condition  of  the  bones.  In  rudimentary 
femur  an  artificial  limb  with  a  trigger-lock  at  the  knee  gave  satisfaction. 
Amputations  at  the  knee  were  performed  in  a  number  of  instances  for  absence 
of  the  tibia.  Albert  preferred  a  more  conservative  method,  and  performed  an 
intercondyloid  resection  of  a  wedge-shaped  piece,  so  that  the  fibula  would 
come  more  directly  in  the  line  of  support.  Tenotomy  and  the  use  of  an 
apparatus  may  suffice  to  bring  the  foot  into  an  improved  position.  In  bilateral 
absence  of  the  tibia  if  the  fibulas  be  normal,  amputation  should  be  deferred  as 
long  as  possible,  and  tenotomies  and  braces  should  be  employed,  since  in 
Parker's  case  the  patient,  in  whom  the  deformity  was  bilateral,  was  able  at 
three  years  of  age  to  support  himself  and  walk  upon  the  fibulas. 


CHAPTER  XXXI. 
ACCIDENT  OR  TRAUMATISM. 

Many  chronic  conditions  the  result  of  accident  or  traumatism  come  under 
the  care  of  the  orthopedic  surgeon.  The  distinction  between  orthopedic  and 
general  surgery  is  here  very  narrow,  and  is  often  a  matter  of  chronicity  rather 
than  any  other  consideration. 

These  include  dislocations  of  tendons  and  cartilage,  and  irreducible  dislo- 
cation of  bones,  ununited  fracture  producing  deformity,  and  rupture  of  muscular 
tissue  and  tendons,  together  with  a  brief  consideration  of  the  contractures  and 
ankylosis  which  frequently  result  from  injury  or  disease. 

Dislocation  of  Tendons. 

Dislocations  of  the  tendons  as  a  result  of  traumatism  are  most  common 
in  the  long  head  of  the  biceps,  the  peroneal  tendons,  the  posterior  tibial  tendon, 
and  the  latissimus  dorsi. 

The  long  head  of  the  biceps  may  be  displaced  from  the  bicipital  groove 
by  violence.  It  is  easily  recognized,  but  the  injury  is  not  frequently  met  with, 
since  rupture  of  this  tendon  is  more  apt  to  occur.  The  tendon  should  be 
replaced  and  the  arm  held  in  a  Velpeau  position  and  secured  with  a  bandage. 
If  repeated  dislocations  occur,  operation  may  be  undertaken  to  secure  the  tendon 
in  the  groove  by  a  plastic  or  osteoplastic  flap,  or  it  may  be  sutured  into  place 
with  silk. 

Dislocation  of  the  peroneal  tendon  has  already  been  referred  to  in  connec- 
tion with  the  paralytic  calcaneus.  The  peroneus  longus  and  bre\ds  may  either 
or  both  be  dislocated  forward  in  front  of  the  external  malleolus,  or  the  peroneus 
tertius  may  be  displaced  from  its  normal  position  and  be  recognized  as  a  round 
cord  on  the  dorsum  of  the  foot.  The  treatment  consists  in  replacing  the  tendon 
and  securing  it  in  an  artificial  groove  by  means  of  silk  sutures,  or  an  osteo- 
plastic flap  made  for  the  reception  of  the  tendon. 

The  tibialis  posticus  tendon  may  be  dislocated  forward  so  that  it  lies  in  front 
of  the  internal  malleolus,  cases  of  this  kind  having  been  reported.  The  accident 
is  a  rare  one  on  account  of  the  anatomic  advantages  of  the  internal  ankle  and 

904 


ACCIDENT  OR  TRAUMATISM.  905 

the  secure  position  of  this  tendon.     It  should  be  reduced  and  retained  in  position 
by  adhesive  plaster  and  a  cast.     Its  reduction  is  usually  permanent. 

The  latissimus  dorsi  tendon  may  be  torn  from  its  position  at  the  lower  angle 
of  the  scapula,  producing  a  displacement  of  the  scapula,  sometimes  resembling 
incipient  scoliosis.  A  depression  is  noticed  beneath  the  lower  angle  of  the 
scapula  and  the  shoulder  cannot  be  held  in  its  proper  position  by  voluntary 
effort.  The  treatment  consists  in  making  an  incision  over  the  inferior  angle  of 
the  scapula  and  attaching  the  fibrous  tendon  of  the  latissimus  dorsi  to  the  scapula 
by  silk  sutures.  A  heavy  pad  should  be  placed  over  the  scapula  and  the  arm 
should  be  secured  to  the  side  by  a  pi aster-of -Paris  bandage. 

Dislocation  of  Cartilage. 

Under  dislocation  of  cartilage  should  be  considered  dislocation  of  the  semi- 
lunar cartilage  of  the  knee  and  diastasis  of  the  epiphysis  of  the  tibia.  The 
former  has  already  been  described  in  its  proper  place. 

Diastasis. — Diastasis  is  a  separation,  pathologic  or  spontaneous,  of  the 
epiphysis  from  the  diaphysis.  It  is  also  known  as  separation  at  the  epiphyseal 
juncture. 

Diastasis  is  an  affection  of  youth  and  early  adult  life,  and  occurs  usually 
as  the  result  of  direct  violence,  but  may  occur  from  indirect  violence  or  an 
inflammatory  process  taking  place  at  the  epiphysis.  One  of  the  best  examples 
of  diastasis  occurs  between  the  first  and  second  portions  of  the  sternum,  this 
region  being  also  the  seat  of  true  dislocation,  a  true  joint  having  been  observed 
in  this  situation. 

True  diastasis  as  the  result  of  disease  or  traumatism  may  occur  in  any 
part  of  the  skeleton,  but  in  this  connection  only  those  which  resemble  or  com- 
plicate joint  disease  in  the  extremities  will  be  considered.  The  most  common 
seats  are  the  upper  part  of  the  femur,  the  upper  part  of  the  humerus,  the  lower 
part  of  the  humerus,  and  the  upper  part  of  the  tibia. 

In  some  cases  the  epiphysis  is  pushed  off  by  granulations,  and  in  the  case 
of  the  upper  part  of  the  femur  the  head  of  the  bone  may  be  found  loose  in  the 
cavity  of  the  joint.  More  frequently  it  results  from  direct  or  indirect  traumatism, 
in  the  reduction  of  dislocations,  of  ankylosis,  and  in  the  correction  of  rachitic 
deformities  by  manual  or  instrumental  means.  Epiphyseal  separation  of  the 
humerus  is  occasionally  seen  in  the  newborn  as  a  result  of  traction  upon  the 
arm.     It  is  most  frequently  seen  between  the  tenth  and  fifteenth  year. 

Agnew,  Barwell,  Marsh,  and  others  refer  to  this  accident,  and  Hamilton 


906  ORTHOPEDIC  SURGERY. 

refers  to  three  cases  recorded  by  South,  Parker,  and  Post.  Separation  of  the 
head  of  the  tibia  has  been  recorded.  Epiphyseal  separation  occurs  most  fre- 
quently at  the  upper  end  of  the  humerus.  In  49  cases  reported  by  v.  Bruns 
the  upper  end  of  the  humerus  was  involved  in  21  instances. 

The  separation  always  takes  place  between  the  shaft  and  the  cartilage, 
exposing  the  upper  end  of  the  shaft  or  nodular  surface.  Rupture  of  the  perios- 
teum is  not  always  complete,  and  very  often  there  is  a  small  fragment  of  the 
shaft  torn  off  with  the  cartilage  and  epiphysis. 

Following  accident  or  disease  in  a  young  individual  there  is  immediate  short- 
ening, with  great  mobility  and  soft  cartilaginous  crepitus,  and  flexion  and  rotation 
of  the  joint  occasion  no  inconvenience.     Severe  inflammation  may  follow  this  ac- 
cident, and  swelling,  redness,  heat,  and  pain 
are  followed  by  abscess  formation  and  sinuses. 
Union  is  delayed,  bony  union  may  never  occur, 
and  shortening  is  an  almost  constant  sequela. 
Suspected   epiphyseal    fractures    should 
receive  very  careful  attention,  as  they  are  fre- 
quently overlooked,  especially  in  the  young. 
This  is  most  marked  in  epiphyseal  separation 
\  of  the  upper  end  of  the  femur  (coxa  vara  trau- 

y         matica),  where  very  often  there  are  no  defi- 
^        nite  symptoms  until  deformity  becomes  well 
marked.     Diastasis  has  to  be  distinguished 
Fig.  712.-D1ASTASIS   FROM   Caries  Ne-     fj-Q^^  shortening  of  the  limb  from  joint  dis- 

CROTiCA  OF  Tibia  (Banvell).  °  ■> 

ease.  This  may  readily  be  done  by  observ- 
ing that  the  shortening  in  diastasis  occurs  suddenly  in  the  young,  whereas  in 
coxalgia,  knee-joint  disease,  etc.,  it  is  a  late  event  in  the  disease,  and  there  are 
present  the  symptoms  of  articular  disease.  An  examination  by  the  :x:-ray 
should  always  be  made  to  confirm  the  diagnosis. 

\Vlien  this  accident  occurs  during  attempts  to  correct  ankylosis,  or  rachitic 
deformities,  the  use  of  a  plaster  cast  in  the  most  favorable  position  will  be  ad- 
visable. The  surgeon  should  bear  this  accident  in  mind  during  all  orthopedic 
manipulations,  especially  during  the  correction  of  rachitic  curvatures  by  osteo- 
clasis or  hrisement  force. 

Irreducible  Dislocations  of  Articulations.. 

In  this  connection  the  subject  of  irreducible  dislocations  will  be  considered 
only  as  it  applies  to  orthopedic  surgery.     A  dislocation  would  be  considered  an 


ACCIDENT  OR  TRAUMATISM. 


907 


old  and  unreduced  dislocation  if  it  remained  luxated  for  one  or  two  months 
after  the  injury.  The  term  irreducible  is  frequently  a  misnomer,  since  if  one 
method  of  reduction  fails  it  may  often  be  accomplished  by  a  different  form  of 
manipulation. 

Diagnosis, — The  most  important  consideration  in  regard  to  these  disloca- 
tions is  to  make  a  correct  diag- 
nosis, and  this  can  often  be  ac- 
complished only  by  means  of  a 
skiagram.  The  examination  of 
the  part  in  all  its  different  rela- 
tions should  be  carefully  made, 
and  after  the  patient  has  been 
anesthetized  the  skiagram 
should  be  consulted  during 
the  manipulation  of  the  part. 
Many  dislocations  are  compli- 
cated by  fractures  in  their  vicin- 
ity, and  in  all  instances  the  pre- 
vious history  of  the  individual 
as  regards  injury  should  be 
considered,  and  a  careful  com- 
parison of  the  injured  part  with 
its  sound  fellow  should  not  be 
neglected.  No  attempt  at  re- 
duction should  be  made  until 
all  these  points  have  been  noted. 
Certain  conditions,  such  as  con- 
genital dislocation,  tuberculous 
disease  of  the  joints,  coxa  vara, 
and  mialignant  growths,  should 
be  excluded.  The  reduction  is 
frequently  complicated  by  the 

associated  fracture  and  displacement  of  the  fragments  of  the  articulation,  by 
laceration  of  the  soft  parts,  and  by  inflammatory  exudates  and  deposits.  An 
excessive  amount  of  callus  about  the  joint  will  often  complicate  the  reduction, 
but  this  and  many  of  the  other  features  already  mentioned  will  be  shown  in  the 
skiagram. 


Fig.  713. — Dislocation  of  Lower  Exd  of  HtrMERtrs. 


908  ORTHOPEDIC  SURGERY. 

Accidents  of  great  gravity  are  apt  to  occur  during  attempted  reductions, 
such  as  laceration  of  the  great  nerves,  rupture  of  important  vessels,  as  the  axillary, 
and  cases  have  been  recorded  where  the  entire  member  has  been  torn  from 
its  attachment  to  the  body.  Willard  has  collected  twenty-four  cases  in  which 
there  was  injury  to  the  axillary  vessels  during  attempted  reduction.  Of  these, 
there  were  fifteen  which  terminated  fatally,  two  were  uncertain,  in  one  the 
axillary  nerves  were  lacerated  and  in  another  the  brachial  plexus  was  torn  from 
the  spinal  column.  It  is  therefore  very  important  to  gage  carefully  just  how 
much  force  may  properly  be  applied  in  order  to  accomplish  reduction  without 
injury,  and  frequently  it  is  better  to  forego  any  attempt  to  reduce  the  dislocation 
rather  than  to  endanger  the  life  of  the  individual. 

Treatment. — The  operative  methods  employed  for  the  reduction  of  dis- 
locations include  traction  and  manipulation,  extension  and  counter-extension, 
arthrotomy,  and  resection. 

The  methods  employed  by  means  of  traction  and  manipulation  are  fully 
described  in  all  text-books  on  general  surgery  and  need  not  be  epitomized  here. 
Extension  and  counter-extension  are  not  at  the  present  time  employed  to  any 
extent,  since  by  means  of  the  first  method  all  that  is  possible  can  be  accom- 
plished except  in  those  cases  which  require  operative  interference. 

Arthrotomy.  When  manipulations  have  proved  unsuccessful  in  reducing 
the  dislccation,  the  joint  should  be  opened  and  all  the  resisting  structures  should 
be  incised.  The  greatest  care  in  regard  to  aseptic  precautions  should  be 
observed  in  all  these  operations.  In  addition  to  dividing  the  artificial  fibrous 
bands  and  the  removal  of  callus,  the  articular  surfaces  should  be  made  more 
normal  in  outline,  and  foreign  growths  which  have  formed  upon  the  surfaces 
should  be  removed.  The  joints  most  frequently  requiring  arthrotomy  are  the 
shoulder,  elbow,  and  hip. 

In  the  shoulder-joint  access  can  best  be  obtained  by  an  incision  through 
the  outer  side  of  the  cephalic  vein.  Occasionally  it  is  necessary  to  make  another 
incision  on  the  posterior  surface  of  the  joint.  In  the  elbow-joint  arthrotomy 
is  not  very  satisfactory,  and  it  is  usually  necessary  to  resort  to  excision.  When 
the  head  of  the  radius  is  dislocated,  it  may  be  advisable  in  order  to  obtain  a 
useful  joint  to  excise  the  head  of  the  radius.  In  dislocation  of  the  hip  access 
can  be  had  by  an  anterior  incision  from  the  anterior  superior  spine  directly 
dovraward  in  the  longitudinal  plane  of  the  limb.  If  fracture  of  the  neck  of 
the  femur  is  found  to  coexist,  the  femur  should  be  held  in  position  by  means 
of  a  screw  inserted  through  the  outer  side  of  the  trochanter  in  the  direction  of 


ACCIDENT  OR  TRAUMATISM. 


909 


the  neck  of  the  femur.  The  operation  of  Murphy,  consisting  of  the  interpo- 
sition of  fascias  between  the  extremities  of  the  joints,  will  be  found  valuable 
after  the  reduction  of  the  dislocation  if  there  is  a  tendency  to  ankylosis. 


Fig.  714. — Deformities  Affecting  Angle  of  Knee-joint  and  Hip-joint,  Following  Fracture  of  the 

Femue. 


Resection.  Resection  of  the  joint  for  unreduced  dislocations  is  required 
only  in  exceptional  conditions,  and  is  most  useful  in  the  elbow-joint  and  hip- 
joint.  In  the  shoulder-joint,  on  account  of  the  great  mobility  of  the  shoulder- 
girdle,  ankylosis  is  not  so  serious  a  matter  as  in  some  other  articulations.     In 


910 


ORTHOPEDIC  SURGERY. 


performing  excision  in  childhood  it  is  necessary  to  avoid  injury  to  the  epiphysis 
so  as  not  to  interfere  with  the  growth  of  the  part.  In  the  elbow-jomt  excisions 
frequently  give  very  satisfactory  results,  and  the  functional  use  afterward  is 
better  than  that  which  follows  the  operation  of  excision  for  tuberculous  disease. 


Fig.  715.— Deformities  Affecting  Joint  Following  Fractures  of  Tibia. 


In  the  hip-joint,  where  the  dislocation  is  irreducible  by  all  hiown  methods, 
excision  may  be  undertaken,  or  in  those  very  rare  instances  where  the  sciatic 
nerve  is  caught  over  the  neck  of  the  femur,  excision  will  be  found  to  be  the 
only  operation  which  will  afford  any  relief. 


ACCIDENT  OR  TRAUMATISM. 


911 


If  during  the  attempt  to  reduce  the  dislocation  fracture  occurs,  as  at  the 
hip  or  shoulder,  a  better  position  may  be  secured  or  the  deformity  resulting 
may  subsequently  be  corrected  by  osteotomy  or  osteoclasy. 

The  after-treatment  consists  in  very  early  manipulations  of  the  joint, 
massage,  electricity,  and  passive  and  active  movements.  If  on  account  of  the 
length  of  time  which  has  elapsed  or  for  any  other  reason,  reduction  is  impossible 
and  resection  is  contraindicated,  the  limb  should  be  put  in  the  most  favorable 


Fig.  716. — Fracture  of  Lower  Third  of  Fibula  with  Excessive  Callus,  before  Operation. 

position  and   massage  and   manipulations   should    be    employed    to    prevent 
ankylosis. 

Displacement  of  the  Sacrum. 

Attention  has  recently  been  directed  to  displacement  of  the  sacrum. 
This  may  occur  at  the  sacroiliac  articulation,  and  may  be  unilateral  or  bilat- 
eral. The  erect  attitude  resembles  that  of  sciatic  scoliosis,  but  when  the  lower 
extremity  is  h3^erextended,  the  patient  being  in  the  prone  position,  acute  pain 
is  experienced  over  the  body  of  the  gluteus  maximus  muscle  from  pressure 
of  the  internal  lateral  edge  of  the  sacrum  upon  the  sacral  plexus  of  nerves.     The 


912  ORTHOPEDIC  SURGERY. 

treatment  consists  in  recumbency  upon  a  pressure  pad,  followed  by  the  use 
of  pelvic  bandages  and  supports. 

Ununited  Fractures. 

As  a  result  of  improper  setting,  muscular  action,  or  secondary  displace- 
ment, vicious  union  often  occurs,  there  being  overriding  of  the  fragments, 
angular  deformity,  or  rotation  of  the  fragments  upon  their  long  axis.  The 
lower  extremity  is  more  frequently  affected,  there  being  in  the  330  cases  col- 


FiG.  717. — The  Same  as  Fig.  716,  after  Subperiosteal  Excision  of  Fibula. 

lected  by  Bruns  275  in  the  lower  and  55  in  the  upper  extremity.  The  fractures 
in  the  vicinity  of  the  joints  are  most  productive  of  deformity,  either  from  the 
fragments  projecting  directly  into  the  articulation  or  from  excessive  callus.  The 
articulating  surfaces  of  the  bones  are  often  placed  at  a  great  disadvantage  by 
the  rotation  of  the  fragments  upon  their  long  axis. 

Ununited  fracture  or  pseudoarthritis  interferes  with  locomotion  and  de- 
mands orthopedic  treatment. 

The  treatment  of  vicious  union  depends  upon  the  character  of  the 
deformity  and  the  time  since  the  accident.     If  the  callus  is  still  soft,  manual 


ACCIDENT  OR  TRAUMATISM.  913 

refracture  will  be  advisable,  and  the  part  should  be  fixed  in  plaster-of-Paris 
dressing.  If  two  months  have  elapsed,  osteotomy  or  osteoclasis  will  be  found 
necessary  to  correct  the  angular  deformity,  the  former  operation  being  better 
near  the  articulation  and  the  latter  in  the  shaft  of  the  bone.  If  the  fragments 
are  overlapping  or  project  through  the  skin,  it  is  sometimes  necessary  to  remove 
a  portion,  and  in  some  situations,  as  in  the  fibula  or  ulna,  a  subperiosteal 
exsection  may  be  warranted,  particularly  if  the  lower  fragment  be  greatly  dis- 
placed into  the  joint.  Cuneiform  osteotomy  is  sometimes  required  to  correct 
angular  deformity. 

In  pseudoarthrosis  the  resection  of  the  ends  of  the  bones  would  be  indi- 
cated, with  wiring  or  plating  of  the  fragments  in  proper  position.  The  Parkhill 
plates  will  be  found  serviceable  for  this  purpose.  If  the  pseudo-arthrosis  be 
of  recent  origin,  a  leg  brace  will  often  allow  the  patient  to  walk,  and  the  friction 
of  the  ends  may  be  followed  by  firm  bony  union. 

Rupture  of  Muscular  Tissue  and  Tendons. 

Traumatic  rupture  of  muscular  tissue  has  been  referred  to  on  several  occa- 
sions throughout  this  work,  as  rupture  of  the  quadriceps  femoris,  rupture  of 
the  biceps  cubiti. 

Ruptures  of  tendons  from  violence  are  not  uncommon,  but  would  be  more 
frequently  met  if  sprain  fracture  were  not  so  common.  The  periosteum  or 
bony  attachment  yields  before  rupture  of  the  tendon  can  occur. 

The  tendons  most  frequently  torn  by  external  violence  or  muscular  action 
are  the  rectus  femoris,  tendo  patellae,  tendo  x^chillis,  and  flexor  biceps  cubiti. 
The  first  two  have  already  been  referred  to  under  Non-tuberculous  Diseases 
of  the  Knee-joint. 

Rupture  of  the  tendo  Achillis  is  evidenced  by  a  sudden  snap,  accompanied 
by  a  sharp  pain  back  of  the  ankle,  with  loss  of  the  function  of  extension  of 
the  foot  and  a  distinct  depression  over  the  seat  of  rupture  from  separation  of 
the  retracted  ends  of  the  tendon.  The  treatment  consists  in  exposing  the 
tendon  through  a  longitudinal  incision  over  the  back  of  the  tendon,  and 
suturing  the  torn  ends  with  silk,  silver  wire,  or  chromicized  catgut.  The  foot 
should  be  fixed  with  plaster  in  a  position  of  extreme  equinus  for  three  or 
four  weeks. 

Rupture  of  the  long  head  of  the  biceps  cubiti  is  characterized  by  a  relaxa- 
tion of  the  outer  half  of  the  biceps  muscle,  with  contraction  of  the  inner  portion. 
The  treatment  consists  in  the  use  of  an  anterior  right-angled  splint,  or,  better, 


914  ORTHOPEDIC  SURGERY. 

in  suturing  the  torn  ends  together  with  chromicized  catgut  and  fixation  upon 
a  splint. 

Contractures  and  Ankylosis. 

Contractures  and  ankylosis  consist  of  partial  or  entire  immobility  of  an 
articulation  in  any  position,  the  former  term  being  used  when  the  causes  acting 
to  produce  the  immobility  are  extra-articular;  the  latter  is  used  when  the  causes 
are  intra-articular. 

Synonyms. — French,  Anchylose;  Roideur  Articulaire.  German,  Gelenk- 
verwachsung;  Gelenksteifigkeit.    Italian,  ArvcYalosi. 

The  term  ankylosis  {ayyJjkiK^  crooked)  is  derived  from  the  Greek  root 
ay/JjXy)  (ankule),  originally  used  to  express  articular  rigidity  in  a  flexed  position, 
the  term  ipOuy^wXoq  (orthocholos)  being  applied  by  Galen  when  the  limb  was 
fixed  in  a  straight  position.  The  word  is  now  used  interchangeably,  the  terms 
angular  and  straight  being  sometimes  added,  and  the  distinction  being  some- 
times made  of  simple  or  complicated,  associated  with  luxation.  Two  forms 
are  recognized:  true  or  complete,  and  false  or  incomplete.  The  ginglymoid 
or  hinge  joints  are  more  frequently  affected  than  the  ball-and-socket  joints. 

Etiology. — Congenital  ankylosis  is  rare;  Helferich  has  noted  congenital 
ankylosis  in  the  interphalangeal  joint  of  the  thumb  due  to  ossifying  myositis. 
Shands,  of  Washington,  has  related  to  me  a  case  of  congenital  ankylosis  of 
both  elbow-joints,  an  exceedingly  rare  condition.  One  case  has  been  recorded, 
of  a  child  twenty-three  months  old,  with  complete  ankylosis  of  the  entire  skeleton. 

The  affection  is  usually  acquired,  as  a  result  of  non-use,  or  as  sequel  of 
articular  disease,  foreign  bodies,  or  of  fractures  into  the  joints. 

As  the  result  of  non-use,  ankylosis  is  not  uncommon  in  the  aged  in  every 
position  in  society,  and  interesting  examples  have  been  recorded  by  Paget, 
Manzel,  and  Reyher. 

The  tubercular  joint  inflammations  furnish  the  largest  number,  but  gon- 
orrheal, gouty,  rheumatic,  syphilitic,  neurotic,  and  puerperal  affections  also 
lead  to  ankylosis. 

The  question  of  what  produces  and  what  prevents  ankylosis  has  been  a 
subject  for  discussion  among  surgeons  for  some  time,  some  maintaining  that 
if  a  normal  joint  be  immovably  fixed  for  a  certain  length  of  time,  ankylosis  will 
occur,  and  that  motion  is  necessary  in  order  to  preserve  the  normal  integrity 
of  the  joint  and  to  prevent  ankylosis  in  injured  and  inflamed  articulations; 
while  others  have  asserted  diametrically  the  opposite. 


Fig.  71S. — Foreign  Bodies  in  Knee-joixt  (Jones). 


ACCIDENT  OR  TRAUMATISM. 


917 


Both  have  used  the  fakirs  of  India,  who  for  the  sake  of  penance  often 
assurne  one  position  for  years,  as  an  illustration;  one  claiming  that  their  joints 
frequently  become  ankylosed  in  such  an  attitude  (Schreiber),  while  another 
states  that  they,  after  holding  their  limbs  in  one  position  twenty  years,  quickly 
regain  the  normal  use  of  their  joints  after  their  religious  frenzy  has  passed 
(Thomas,  quoted  by  Phelps). 


Fig.  719. — Complete  Bony  Ankylosis  of  Elbow  from  Fr.-^ctuee  of  Humerus. 


The  experiments  of  Phelps  and  Thompson  appear  to  have  proved  that 
neither  of  these  statements  about  rest  and  motion  is  correct,  but  that  the  question 
of  ankylosis  is  determined  by  the  severity,  character,  and  duration  of  the 
inflammation,  the  presence  of  intra-articular  pressure,  the  subsequent  cicatricial 
contraction  of  soft  parts  around  the  joints,  the  tissue  involved,  and  the  amount 
of  destruction  of  bone  and  cartilage.     Contractures  may  be  due  to  the  following 


918 


ORTHOPEDIC  SURGERY. 


causes:  burns,  lupus,  ossifying  myositis,  adliesions  between  tendons  and  their 
sheaths  or  shortening  by  retraction,  paralysis  or  division  of  nerves  of  antago- 
nistic muscles,  incised  wounds  of  tendons,  shortening  of  muscles  following 
central  and  peripheral  nerve  affections;  ischemic  degeneration  of  muscles  caused 
by  constricting  dressings,  extensive  destruction  of  tissue  following  phlegmenous 
ulcers,  and  occupational  diseases  in  persons  who  do  uninterrupted  work  of 
the  same  nature  for  long  periods,  as  seen  in  "writer's  cramp,"  etc. 

Pathology. — In  true  ankylosis  the  articular  ends  of  the  bones  are  united 
by  osseous  material  within  the  joint,  without  the  joint  as  synostosis,  or  by  both. 


Fig.  720. — Scoliosis,  showing  Deporjiiiy  of  Ribs,  with  Ankylosis. 


Preceding  the  union  of  the  bones  there  has  been  destruction  and  absorption 
of  synovial  membrane,  of  cartilage,  and  the  joint  has  been  obliterated  by  car- 
tilaginous or  fibrous  material. 

In  false  ankylosis  the  mtra-articular  changes  are  largely  S}-novial,  consisting 
of  false  bands,  cicatricial  contractions,  cohesion  of  the  ligamentous  capsule, 
or  complete  disorganization  by  inflammatory  deposits.  Cicatricial  contractions 
of  skin,  fascia,  tendons  of  muscles,  all  are  of  this  false  variety. 

Diagnosis. — A  positive  diagnosis  between  true  and  false  ankylosis  can 


ACCIDENT  OR  TRAUMATISM.  919 

only  be  determined  under  anesthesia.  When  the  ankylosis  is  osseous,  the 
articulation  remains  immovable  under  complete  narcosis. 

Prognosis. — The  prognosis  at  the  present  time  is  generally  favorable 
under  modem  surgical  methods. 

Treatment. — Treatment  should  not  be  undertaken  until  the  original 
articular  disease  has  disappeared  or  has  been  overcome  by  appropriate  treat- 
ment, since  too  early  manipulation  may  hasten  what  the  surgeon  is  striving 
to  overcome. 

The  reduction  in  mild  cases  of  false  ankylosis  can  be  accomplished  by 
massage,  and  by  gradual  manual  and  elastic  traction.  In  more  severe  cases  forci- 
ble reduction  (hrisement  force)  may  be  performed  with  or  without  anesthesia.  In 
doing  this  the  rule  employed  by  the  bone-setter  should  be  followed  accurately, 
to  make  firm  pressure  upon  the  tender  spot  at  the  moment  the  greatest  force 
is  exerted.  The  greatest  caution  and  gentleness  are  at  first  necessary  until 
the  rigidity  begins  to  yield,  lest  fracture  result,  as  it  frequently  has  done  in  the 
hands  of  the  most  skilful  surgeons. 

The  first  movement  should  be  in  the  direction  of  flexion,  and  forced  flexion 
is  often  beneficial.  When  the  false  ankylosis  is  very  firm,  instrumental  force 
must  be  resorted  to,  and  osteoclasts  of  the  preferred  pattern  may  be  used. 
Tenotomy  is  often  required,  and  where  necessary  should  be  first  performed. 

In  true  ankylosis  osteotomy  or  cuneiform  resection  is,  as  a  rule,  necessary; 
but  amputation  is  rarely  warranted  since  the  advent  of  antiseptic  surgery. 

The  consideration  of  ankylosis  of  the  individual  joints  will  be  found  in 
their  respective  sections. 


NDEX. 


[Page  numbers  in  boldfaced  type  are  those  sections  particularly  and  fully  described.] 


A. 

Abscess,  245 

acetabular,  318 

arthritic,  31S 

bone,  68 

cervical,  228 

cold,  72,  73 

external  lumbar,  232 

gluteal,  232,  319 

iliac,  98,  232 

in  ankle-joint  disease,  463,  464,  467 

in  elbow-joint  disease,  491,  492,  494 

in  infectious  osteomyelitis,  517 

in  Pott's  disease,  214,  227,  245 

in  sacro-iliac  disease,  296,  297, 

in  shoulder-joint  disease,  477,  478 

in  suppurative  arthritis  of  the  knee,  446,  447 

in  tuberculous   disease  of  the  metacarpals,   504 
of  the  tarsus,  471 

internal  crural,  319 
lumbar,  232 

joint,  74 

lumbar,  97,  231,  232,  264,  265 

mediastinal,  229 

periarticular,  524 

pericecal,  245 

perinephritic,  245 

pointing  of,  228 

postpharyngeal,  229 

psoas,  220,  230,  246,  264,  265,  306 

pubic,  319 

residual,  227,  248,  317 

retropharyngeal,  229,  263 

subperiosteal,  518 
Abscesses,  pointing  of,  22S 

table  of  spinal,  232 
Absence,  congenital,  of  parts,  290,  487 
of  clavicle,  896 
of  pectoral  muscles,  290 
of  ribs,  291 
of  sternum,  289 
of  vertebrae,  290 
Absorption  of  bone,  210 
Accident,  904 
Acetabular  abscess,  318 

coxalgia,  308,  315,  339 
Achillodynia,  833 
Acid,  carbolic,  in  tuberculous  joint  disease,  86 

in  erasions,  205 
Acquired  deformities,  19 

of  the  thorax,  291 

syphilitic  joint  disease,  526 
Acromegaly  of  the  spine,  277 
Acromial  bursitis,  481 
Actinomycosis  of  the  spine,  277 
Acute  arthritis  of  hip-joint,  378 

articular  rheumatism,  533 
varieties  of,  533 

infantile  paralysis,  612 

prepatellar  bursitis,  447 

differential  diagnosis  from  synovitis,  444 

rheumatic  arthritis,  422 


Acute  serous  synovitis,  513 

synovitis  of  knee,  442 
sprains  of  ankle-joint,  473 
subdeltoid  bursitis,  480 
suppurative  arthritis  of  infancy,  524 

of  knee,  446 
tenosynovitis  of  ankle-joint,  474 
in  wrist,  505 
Adams'  method  of  examining  back,  243 

operation  for  hip-joint  disease,  363,  364 
Adapted  atrophy,  61S 
Adhesive  plaster  dressings,  141 

for  sprained  ankle,  473 
Adolescent  kyphosis,  272 

rickets,  718 
Affections  of  the  feet,  823 
Achillodynia,  833 
claw-foot,  829 
displacement  of  toes,  829 
erythromelalgia,  836 
exostoses  of  tarsal  bones,  S3  6 
hallux  metatarsus,  833 
rigidus,  832 
valgus,  830 
varus,  832 
hammer-toe,  828 
lateral  deviation  of  toes,  830 
metatarsalgia,  823 
painful  heel,  835 
plantalgia,  S37 
pododynia,  837 
pronation,  826 
retro-calcaneal  bursitis,  834 
sprains,  826 
Agenese  cerebrale,  649 
Akut  encephalitis  der  Kinder,  649 
Aluminum  corsets,  164 
American  history  of  orthopedic  surgery,  12 

method  of  treating  joint  disease,  12,  353 
Amniotic  theory,  19 
Amputation,  166,  206 

in  ankle-joint  disease,  468 
in  club-foot,  789 
in  elbow-joint  disease,  496 
in  infantile  spinal  paralysis,  646 
in  shoulder-joint  disease,  479 
in  suppurative  arthritis  of  the  knee,  447 
in  tenosynovitis  of  wrist,  50S 
in  tuberculous  disease  of  the  metacarpals,   504 
of  the  tarsus,  471 
joint  disease,  89 
in  wrist-joint  disease,  503 
Anastomosis,  musculo-tendinous,  176 

of  nerves,  197,  645 
Anatomy  of  foot,  759 
Anchilosi,  914 
Anchylose,  914 

Anderson  method  of  tenotomy,  176 
Anencephalus,  16 

Angelborener  Hochstand  der  Scapula,  4S6 
Angina  of  Hippocrates,  5 
Angle  of  feet  in  standing,  551 


922 


INDEX. 


Angle  of  inclinarion  in  normal  foot,  551 
Angular  curvature,  207 

defonnity,  211,  222 
Ankle-joint  disease,  463 

resection  of,  468 

sprains  of,  472 
Ankylosis,  49,  56,  752,  758  914 

bony,  56 

false,  59,  918 

fibrosa,  56 

in  acute  arthritis  of  hip-joint,  377 

in  elbow-joint  disease,  493,  494 

in  gonorrheal  arthritis,  531 

in  hemophiliac  arthritis,  537 

in  infectious  osteomyeUtis,  518 

in  loose  shoulder-joint,  482 

in  syno\-itis  of  hip-joint,  377 

in  syphUitic  joint  disease,  526 

in  wrist-joint  disease,  502 

ossia,  56 
,   resections  for,  206 

treatment  of,  171 

true,  56,  918 
Anterior  bow-legs,  745 

poHomyelitis,  nerve  anastomosis  in,  197 
in  infantile  spinal  paralysis,  603,  607 

tarsectomy,  471 
Aortic  aneurisms,  243 
Aponeurotomy,  196,  645 

Bradford's,  459 

for  recurrent  dislocation  of  shoulder-joint,  482, 
484 
Apparatus  for  loose  shoulder-joint,  4S2 

Frazier-Lentz,  129 

hot  air,  129 

Marsh,  435 

orthopedic,  141 

pendulum,  123 

Sargent,  122 

Tellerman-ShefEeld,  129 
Application  of  plaster-of-Paris  jacket,  253 
Archioterigium  theory,  16 
Arrest  of  development,  theory  of,  16,  76S,  844 
Arthrectomy,  89,  478,  495 

partial,  502 
Arthrite  plastique  ankylosante,  377 
Arthritic  abscess,  31S 

coxalgia,  315,  339  .  . 
Arthritis,  acute,  of  hip-joint,  378 

chronica  ulcerosa  sicca,  751 

deformans,  38,  751 
of  hip,  379 

gonorrheal,  44,  513 

medullo-,  301 

osteo-,  379 

pauperum,  377 

rheumatoid,  244,  379,  752 

strumous,  407 

suppurative,  521 

traumatic,  519 

tuberculous,  59 

urica,  535 

vertebral,  207 
Arthrodesis,  11,  205,  646 
Arthropathy,  neural,  703 

spinal,  703 

tabetic,  703 
Arthrotomy  in  congenital  dislocation  of  the  hip,  873 

in  diastasis,  908 

in  gonorrheal  arthritis,  533 

in  suppurative  arthritis,  523 

in  syphilitic  joint-disease,  5  28 
Articular  osteitis  of  the  hip,  301 

resections,  206 


Articuli  duplicati,  715 
Artificial  limbs,  164 
Artriti  reumatoida.  751 
Artritis  reumatoida,  751. 
Aspiration  in  hip-joint  disease,  367 

of  gangUon,  508 

of  joints,  361 
Astragalectomy,  471,  780 
Astragalus,  tuberculous  disease  of,  470 
Asymmetry,  711 
Ataxia,  hereditar>',  684 
Atrophic  paralysis,  603 
Atrophie  partielle  cerebrale,  649 

progressive  musculaire,  676 
Atrophische  cerebrallahmung,  649 
Atrophy  in  deformit)-,  26 

in  unilateral  development,  711 

progressive  muscular,  676 
Attitude  in  acute  epiphysitis  of  the  hip,  97 

in  cerebral  palsy,  98 

in  cervical  caries,  98,  219 

in  deformit)',  97 

in  dorsal  caries,  220 

in  hip-joint  disease,  98,  331 

in  Uiac  abscess,  98 

in  infantile  spinal  palsy,  97 

in  lumbar  abscess,  97 
caries,  220 

in  obstetric  paralysis,  485 

in  Pott's  disease,  98,  219 

in  progressive  muscular  atrophy,  98 
Avocation,    influence    of,   in    producing    deformity, 
291 


Back,  Adams'  method  of  examining,  243 

flat,  273 

hoUow,  273 

round,  273 

round-hoUow,  273 
Backerbein,  727 

Bacteriologi.'  in  diagnosis  of  deformity-,  98 
Balanced  sitting  position,  571 
Ballottement,  513 
Bandages,  bed,  142 

couch,  142 

many-tailed,  141,  142 

plaster,    in   congenital    dislocation    of    hip,  861, 
863 
Bandy-legs,  739 
Barrel-legs,  739 
Baxwell's  sling,  142 
Bayer's  tenotomy,  177 
Bed  bandages,  142 

bent  frame,  149,  251 

Phelps'  plaster-of-Paris  portable,  142 
Beely  machine,  123 
Bending  forceps,  139 

irons,  139 

of  the  neck  of  the  femur,  384 
Bent  .bed  frame,  149,  251 
Biceps,  rupture  of,  487 

tenotomy  of,  188 
Bier's  passive  congestion  treatment,  87 
BiDroth's  myotomy,  360 
Blenorrhoea  infantilis,  246 
Bogenformige  Deformitat  der  Wirbelsank,  539 
Bone,  abscess,  68 

absorption,  210 

chisel,  199 

drill,  200 

furunculosis,  517 

infarct,  71 


INDEX. 


923 


Bone  knife,  199 
Bony  ankylosis,  56 
Bow-legs,  28,  739 
•    anterior,  745 

braces,  130,  744 

diagnosis  of,  740 

etiology  of,  739 

prognosis  of,  740 

symptoms  of,  740 

synonyms  of,  739 

treatment  of,  743 
hygienic,  743 
mechanical,  744 
operative,  744 

varieties  of,  739 
Braatz  models,  162 
Braces,  bow-leg,  130,  744 

knock-knee,  733 

leg,  140 

outlines  for,  130 

spine,  130,  344,  592 
for  lordosis,  286 
Bradford's  apparatus,  459,  566,  596 
Breast,  pigeon,  227,  289,  291 
Brisement  forc^  in  club-foot,  7S6,  821 

in  hip-joint  disease,  361 
Buck's  extension,  344 

scoliosometer,  566 
Bursa,  popliteal,  451 

prepatellar,  447 

pretibial,  449 
Bursae  of  wrist-joint,  505 
Bursitis,  acromial,  481 

acute  prepatellar,  443,  447 

diagnosis  from  synovitis  of  knee,  444 

gluteal,  405 

of  hip-joint,  405 

olecranon,  499 

prepatellar,  447 

pretibial,  449 

retro-calcaneal,  834 

subcoracoid,  481 

subdeltoid,  480 

subscapular,  481 

subserrate,  481 


Calcaneum,  tuberculous  disease  of,  470 

Calcareous  deposits  in  tenosynovitis  of  wrist,  506 

Caliper,  105 

Caput  obstipum,  687 

CarboUc  acid  in  erasions,  205 

in  tuberculous  joint  disease,  86 
Carcinoma  of  spine,  278 
Caries,  attitude  in,  98,  219,  220 

cornosa,  477 

mollis  sue  fungosa,  59,  407 

necrotica,  211 

of  spine,  207 

sicca,  59,  75,  214,  276,  407,  477 
Carrying  angle  of  forearm,  498 
Cartilage,  dislocation  of,  905 

exfoliation  of,  514 
Caseation,  67,  210 
Casts,  plaster,  no 

in  congenital  dislocation  of  hip,  861,  863 
Cautery,  Paquelin,  368 
Cells,  endothelial,  66,  67 

epithelioid,  67 

giant,  67 

lymphoid,  67,  68 

mononuclear,  67 

multinuclear,  67 


Celluloid  splints,  158 
Center  of  gravity  in  standing,  551 
Cerebral  palsy,  647 
age  in,  647 

amaurotic  family  idiocy,  669 
attitude  in,  98,  657 
etiology  of,  648 

hemiplegia,  bilateral  spastic,  651 
infantile,  649 
palsies,  647 

differential  diagnosis  of,  657 
processes  of,  657 
prognosis,  658 
treatment  659 

asexualization,  664 
circumcision,  669 
craniectomy,  664 
hygienic,  659 
nerve  anastomosis,  662 
tendon  grafting,  661 
tenoplasty,  660 
tenotomy,  660 
Cerebrale  Kinderlahmung,  647 
Cervical  abscess  in  Pott's  disease,  228 

caries,  attitude  in,  98,  219 
Chair,  Cotton's,  573 

Miller's,  573 
Charcot's  disease,  703 
Chest,  flat,  289,  291 
funnel,  289,  291 
Chin  rest,  255,  261 
Chisel,  bone,  199 
Chondrectomy,  204 
Chondrodystrophia,  275 
Chondrotomy,  204 

Chorea  from  acute  articular  rheumatism,  534 
Chronic  articular  osteitis  of  hip,  301 
prepatellar  bursitis,  448 
purulent  synovitis  of  knee,  407 
serosynovitis  of  hip,  377 
.    serous  synovitis,  514 
of  knee,  443 
sprain  of  ankle-joint,  473 
subdeltoid  bursitis,  480 
tenosynovitis  of  ankle,  474 

of  wrist,  505 
tubercular  osteitis  of  knee,  407 
Ciphosi,  207 

Classification  of  deformity,  90 
of  orthopedic  diseases,  91 
Clavicle,  absence  of,  290,  487 
Claw-foot,  829 
Cleft-palate,  16 
Club-foot,  759 

acquired  forms,  769 
anatomy  of  foot,  759 
diagnosis  of,  770 
etiology  of  acquired  forms,  769 

of  congenital  forms,  766 
neuromimesis  in,  806 
iiou-deforming,  805 
pes  cavus,  805 
planus,  806 
valgus  acquisitus,  792 
paralytica,  794 
prognosis  of,  771 
relative  frequency  of,  764 
symptoms  of,  770 
synonyms.  759 
theories  of,  766 
treatment  of,  772 
casts,  810 
electricity,  773 
manipulations,  772,  819 


924 


INDEX. 


Club-foot,  treatment  of,  massage,  773,  S19 
mechanical,  810 
operative,  776 

amputation,  789 
astragalectomy,  780 
brisement  force,  786   821 
Gleich's  operation,  814 
of  special  varieties,  808 
open  incision,  78S 
retentive  dressings,  819 
syndesmotomy,  776 
tarsectomy,  777,  780,  821 
tarsotomy,  777,  S21 
tenotomy,  776,  821 
shoes,  141,  809 
splints,  773 
springs,  810 
wrenches,  172,  787 
varieties  of,  763 

specially  considered,  789 
compound  forms,  799 
other  forms,  805 
simple  forms,  789 
Club-hand,  883 
Coagulation  necrosis,  67 
Cold  abscess,  72,  73 
Colloid  cysts,  508 
CoUum  distortum,  687 

femoris  varum,  384 
Compensatory  lordosis  in  dislocation  of  hip,  286 

in  dislocation  of  patella,  286 
Compression  for  synovitis  of  knee,  443 

myelitis,  215,  216,  236 
Congdon  joint,  140 
Congenital  absence  of  clavicle,  487 

contractions  of  fingers  and  toes,  891 
cubitus  valgus,  498 

varus,  498 
deficiencies  of  fingers,  885 

of  parts,  896 
deformities  of  the  chest,  289 
deformity,  15 

etiology  of,  15 
frequency  of,  92 
prophylaxis  of,  118 
dislocation  of  the  elbow,  881 
of  the  hip,  838 
at  birth,  845 

bilateral,  84S,  852,  855,  862 
deformity,  851 
diagnosis  of,  S53 
etiology  of,  839 
frequency  of,  83S 
gait  in,  851,  S52 
gymnastic  exercises  in,  864 
in  adults,  S48 

in  children  who  have  walked,  846 
massage  in,  866 
pain  in,  852 
pathology  of,  844 
prognosis  of,  854 
symptoms  of,  851 
theories  of,  S40 

arrest    or    defect  of    development, 

844 
heredity,  840 

mechanical    or    intrauterine    pres- 
sure, 841 
pre-natal  disease,  843 
treatment  of,  85  6 
apparatus,  856 
extension,  856 
forcible  reduction,  857 

method  of  Hoffa,  870 


Congenital  dislocation  of  the  hip,  treatment  of,  forc- 
ible  reduction,    method 
of  Lorenz,  858 
method  of  Paci,  857 
mechanical,  871 
operative,  872 

arthrotomy,    or    formation    of 

new  cavity,  873 
osteotomy,  877 
resection,    or    decapitation    of 

femur,  873 
tenotomy,  S72 
unilateral,  849,  850,  851,  855,  863 
of  the  knee,  877 
of  the  patella,  456,  459 

compensatory  lordosis  in,  286 
of  the  shoulder,  879 
elevation  of  the  scapula,  486 
tumors  of  fingers  and  toes,  89S 
union  of  fingers  and  toes,  888 
Congestion,  passive,  87,  479,  494 
Constitutional  deformities,  37 
Continental  period  in  orthopedic  history,  5 
Contraction  des  doigts,  892 
Contractions,  congenital,  of  fingers  and  toes,  891 

Dupuytren's,  892 
Contractures,  49 

from  hemophiliac  joint  lesions,  537 
from  nervous  lesions,  55 
Hoffa's  classification  of,  50 
of  fascias,  50 
of  joints,  56 
of  muscles,  50 
of  skin,  50 
of  tendons,  50 
Contractures  and  ankylosis,  914 
acquired,  914 
causes  of,  91S 

cicatricial  contraction  in,  915 
congenital,  914 
diagnosis  of,  918 
etiology  of,  914 
false,  59,  9 18,  919 
osseous,  919 
pathology,  908 
prognosis,  919 
reduction  of,  919 
synonyms,  9x4 
treatment,  919 
true,  56,  918 
Corsets,  aluminum,  164 
leather,  255 
Morton,  272 
wooden,  r62,  255 
Cotton's  chair,  573 

Cottrell's  adhesive  plaster  dressing,  473 
Couch  bandages,  142 
Counter-irritation  in  bursitis,  448 
in  synovitis  of  knee,  443 
in  tuberculous  joint  disease,  86,  479 
Cou  tortu,  687 
Coutors,  687 
Coxa  abducta,  402 
adducta,  384 
valga,  402 
vara,  384 

adolescentium,  386 
age  in,  386 
bilateral,  390 

symptoms  of,  390 
classification  of,  according  to  deformitv, 

388 
deformity  in,  387 
angle  of,  387 


INDEX. 


925 


Coxa    vara    adolescentium,     deformity    in,     scissor- 


diagnosis,  395 

differential  diagnosis,  395 

arthritis  deformans,  395,  396 
congenital    dislocation  of  hip, 

.395 
hip  disease,  395 
osteomalacia,  395 
osteomyeUtis,  395 
traumatic  coxa  vara,  395 
duration  of  symptoms  in,  390 
pathology,  395 
rachitis  in,  395 
sex  in,  387 
symptoms,  389 
atrophy,  389 
deformity,  388,  389 
exacerbations  of,  390 
gait,  389,  390 
limp,  389 

muscle  spasm,  389 
objective,  389 
of  bilateral  form,  390 
pain,  389 
scissors  gait,  390 
subjective,  389 
classification  of  varieties  of,  385 
congenital,  396 
definition  of,  3S4 
due  to  acute  osteomyelitis,  396 
due  to  arthritis  deformans,  397 
due  to  causes  not  known,  397 
due  to  osteitis  fibrosa,  396 
due  to  osteomalacia,  396 
due  to  senile  atrophy,  397 
due  to  tuberculosis,  397 
etiology,  3S4 

anatomic  theory,  385 
congenital  theory,  384 
pathologic  theory,  384 
static  theory,  3S5 
Sudeck's  theory,  385 
theory  of  inherent  weakness,  385 
theory  of  structural  weakness,  385 
traumatic  theory,  385 
history  of,  384 
synonyms  for,  384 
traumatic,  397 
Coxalgia,  301 

acetabular,  30S,  315,  339 
arthritic,  315,  339 
femoral,  315,  339 
Coxalgie,  301 

hysterique,  338 
Coxarthrocace,  301 
Coxite,  301 
Coxitis,  301 

senile,  379,  75S 
Coxopathie,  301 
Coxo-tuberculose,  301 
Coxo-tuberculosis,  301 
Crepitation,  444,  497,  506 

leathery,  513 
Crumpled  toe,  37 
Crural  abscess,  internal,  319 
Cniveilhier's  atrophy,  676 

paralysis,  676 
Cryer's  electric  drill,  200 
Cubitus  valgus,  congenital,  498 
in  rickets,  498 
varus,  congenital,  498 
Cuboid,  tuberculous  disease  of,  470 
Cuirass,  felt,  160 


Cuneiform  osteotomy,  203 
Curetage,  88 

Curetment  in  wrist-joint  disease,  502 
Curvature,  angular,  207 

lateral,  539 

posterior,  207 
Cyphose,  207 
Cyrtometer,  564 
Cystitis  in  Pott's  disease,  236 
Cysts,  colloid,  508 

hydatid,  of  hip,  405 

popliteal,  451 

D. 

Decubitus,  effect  of,  in  pigeon  breast,  292 
Deep  pretibial  bursa,  449 
Defective  pectoral  muscles,  290 
Deficiency,  congenital,  of  lingers,  885 

of  parts,  896 
Deformations  du  col  du  femur,  384 
Deformities,  acquired,  19 

congenital,  2S9,  838,  877,  879,  881,  885,  888,  89 1, 

895,  8g6 
constitutional,  37 
habitual,  19 

in  hemophiliac  joint  lesions,  537 
in  infantile   spinal  paralysis,  617,  618,  619,  621 
of  feet,  37 

of  fingers  and  toes,  884 
of  the  thorax,  289 
etiology  of,  289 
influence  of  naso-pharyngeal    affections    in, 

293 

prognosis  of,  294 

treatment  of,  294 

varieties  of,  289 
static,  19 
vestmentary,  29 
Deformity,  angular,  of  spine,  211,  222 
atrophy  in,  26 
attitude  in,  97 
classification  of,  90 
congenital,  15 
diagnosis  of,  98 
diet  in,  119 
divisions  of,  15 
etiology  of,  15 

following  acute  suppurative  arthritis  of  knee,  447 
forcible  correction  of,  171 
frequency  of,  91 
from  absence  of  clavicle,  290 
from  absence  of  pectoral  muscles,  290 
from  absence  of  ribs,  29  r 
from  increased  number  of  ribs,  291 
general  statistics  of,  90 
general  symptoms  of,  96 
gunstock,  499 

in  ankle-joint  disease,  464,  466 
in  congenital  elevation  of  scapula,  486 
in  elbow-joint  disease,  492 
in  Pott's  disease,  222 

correction  of,  255 
in  shoulder-joint  disease,  477 
in  snapping  knee,  460 
in  spondylolisthesis,  288 
in  suppurative  arthritis  of  infancy,  524 
in  synovitis  of  hip-joint,  377 
in  tenosynovitis  of  wrist,  506 
manual  correction  of,  171 
mechanical  correction  of,  r7r 
mental  effect  of,  96 
physiognomy  in,  96 
posterior,  272 


926 


INDEX. 


Defonnity,  prognosis  of,  no 

prophylaxis  of,  Il8 

rachitic,  37,  no,  291 

Rontgen  ray  in  diagnosis  of,  109 

scissor-Ieg,  236,  325,  3S8 

spontaneous  recovery  from,  no,  117 

Sprengel's,  4S6 

treatment  of,  119 
hygienic,  iig 
local,  130 
medical,  120 
operative,  171 
results  of,  117 

varieties  of,  15 
Degenerative  ataxia,  684 
Delineator,  improved  trolley,  567 
Depression  of  neck,  of  femur,  3S4 
Destructive  osteitis,  210 
Detachable  joints,  139 
Development,  arrest  of,  16 

partial,  of  sternum,  290 
Deviation  laterale  de  la  taille,  539 
Diastasis,  905 
Diathesis,  strumous,  209 
Die  Dupuytrenische  Contraction  der  Finger, 
Diet  in  deformity,  119 
Disability  in  rupture  of  biceps  muscles,  4S8 
Discission  of  ganglion,  509 
Dislocation,  congenital,  of  elbow,  881 
of  hip,  838 
of  knee,  877 
of  shoulder,  879 

irreducible,  906 

obstetric,  842 

of  cartilage,  905 

of  patella,  456 

of  semilunar  cartilage,  454 

of  tendons,  904 

recurrent,  of  shoulder-joint,  482 

spontaneous,  of  hip,  402 
Displacement  of  sacrum..  911 

of  toes,  829 
Division  of  plantar  fascia,  183 
Doppelte  Gleider,  715 
Dorsal  caries,  attitude  in,  220 
Dressings,  adhesive  plaster,  141 
Drill,  bone,  200 

Crj'er's  electric,  200 
Drilling  in  hip-joint  disease,  367 
Drop  catch,  139 

finger,  S93 
Dry  syno\'itis  of  hip,  377 
Dyspnea  in  pigeon  breast,  292 
Dystrophy,  muscular,  43 


Early  English  period  of  orthopedic  history,  5 

Ectrodactylism,  885 

Edema  in  suppurative  arthritis,  522 

Effleurage,  124 

Effusion  in  suppurative  arthritis,  522 

in  synovitis  of  knee,  -442 
Elastic  knee-cap,  455,  459 
Elbow-joint,  congenital  dislocation  of,  881 

disease,  490 

loose  bodies  in,  497 
Electric  drill,  Cryer's,  200 
Electricity,  120,  193,  2S6,  294,  631 
Elevation  of  scapula,  congenital,  486 
Elongation  of  patellar  tendon,  461 
Emiplegia  spastica  infantile,  649 
Empyema  in  Pott's  disease,  229, 
Emulsion,  iodoform,  85,  265 


Endocarditis  from  acute  articular  rheumatism,  534 
Endothelial  cells,  66,  67 
Englische  Krankheit,  715 
Enlargement  of  tibial  tubercle,  450 
Entogonyancon,  727 
Epiphysitis  of  hip,  301 

attitude  in,  97 
Epithehoid  cells,  67 

Equino-valgus  in  sprain  of  ankle-joint,  474 
Erasion,  89,  205 

of  bone  in  hemophiliac  joint  lesions,  536 
Erythromelalgia,  836 
Esthetic  gymnastics,  120 
Evacuation  of  abscesses  in  Pott's  disease,  263 
Exanthemata,  62,  210 
Excision  of  joint,  89,  368,  436,  439,  502,  503 

of  osseous  foci,  88 
Excurvation,  spinal,  272 
Exfoliation  of  cartilage  in  synovitis,  514 
Exogonyancon,  739 
Exostoses,  multiple,  43 

of  tarsal  bones,  836 
Exploratory  incision  in  liip-joint  disease,  368 
External  lumbar  abscess,  232 
Extirpation  of  gangUon  sac,  509 
Extra-articular  inflammation,  529 

F. 

Fairbairn  crane,  20 

False  ankylosis,  59,  91S 

Family  ataxia,  684 

Faulty  attitudes  in  producing  deformity,  27 

Federndes  knee,  460 

Feet,  affections  of,  823 

angle  of.  incHnation  in  normal,  551 
in  standing,  551 

impressions  of,  105 
Felt  cuirass,  160 

splints,  159 
Femoral  coxalgia,  315,  339 
Femoro-coxalgie,  301 
Fetal  rickets,  275 
Fever,  urethral,  synovitis  in,  513 
Fibrous  ankylosis,  56 

union  in  rupture  of  biceps  muscles,  488 
Fissured  sternum,  289 
Fist  kneading,  124 
Fistula  in  ano,  132 
Fistulas,  tuberculous,  73 

in  elbow-joint  disease,  492 

in  hip-joint  disease,  320 

in  wrist-joint  disease,  501 
Flat  back,  273 

chest,  2S9,  291 

round  shoulders  in,  291 
treatment  of,  294 

foot,  28,  37,  790 

in  sprain  of  ankle-joint,  474 
traumatic,  474 
Floating  patella,  443,  444,  513 
Fluctuation  in  synoWtis,  513 

in  synovitis  of  the  knee,  443 
Foci,  osseous,  66 

excision  of,  66 

primary  tuberculous,  64,  65,  66,  210,  212 
terminations  of,  71 
Foot,  flat   28,  37,  790 

rubber,  160 

weakened,  37 
Forceps,  bending,  139 

Forcible  correction  of  deformity,  171,  645,  735,  745 
Foreign  bodies  in  hip-joint,  406 
Fracture  of  neck  of  femur,  402 


INDEX. 


927 


Fracture  of  tibial  tubercle,  450 

Fractures,  ununited,  912 

Frazier-Lentz  apparatus,  I2q 

Free  joints,  139 

Free-hand  drawing  in  scoliosometry,  564 

Freidreich's  ataxia,  684 

disease,  6S4 
Friction,  124 
Fulling,  124 

Functional  pathogenesis,  theory  of,  20 
Fungose  arthritis,  59,  407 
Fungous  joint  disease,  59 

synovitis,  310 
of  knee,  407 

tenosynovitis  of  wrist,  506 
Fiuigus  articule,  59,  407 
Funnel  chest,  289,  291 
Furunculosis,  bone,  517 


Gait  in  congenital  chslocation  of  hip,  851,  852 
in  progressive  muscular  atrophy,  675 
in  spondylolisthesis,  289 
scissors,  390 
Galvanopuncture,  120 
Ganglion,  aspiration  of,  509 
discission  of,  509 
extirpation  of,  509 
Gant's  operation  for  section  of  femur,  363 
Gelenkneurose,  699 
Gelenksteifigkeit,  914 
Gelenktuberculose,  59 
Gelenkverwachsung,  914 
Generic  ataxia,  684 
Genou  a  ressort,  460 
cagneux,  727 
endedans,  727 
endehors,  739 
Genu  extrorsum,  739 
introrsum,  727 
valgum,  as  a  cause  for  dislocation  of  patella,  459 

rachitic,  29,  727 
varum,  rachitic,  739 
Giant  cells,  67 
Gigli  savir,  200 

Ginocchio  Torto  all'Indentro,  727 
Gluteal  abscess,  232,  319 

bursitis,  405 
Goldthwait  machine,  172 
Goniometer,  316,  332 
Gonococci,  530 
Gonorrhea  of  spine,  277 
Gonorrheal  arthritis,  528 
ankylosis  in,  531 
arthrotomy  in,  533 
aspiration  in,  532 
diagnosis  of,  532 
frequency  of,  529 
gonococci  in,  530 

order  of  joint  involvement  in,  529 
pathology  of,  529 

extra-articular  inflammation,   529,   530 
influence  of  the  efl'usion  on,  530 
intra-articular  inflammation,  529 
pan-articular  inflammation,  529 
polyarticular  serous  effusion,  530 
polyarticular,  528,  529 
prognosis  in,  532 

as  to  restoration  of  function,  532 
symptoms  of,  531 

with  purulent  infection,  532 
traumatism  in,  52S 
treatment  of,  532 


Gonorrheal  arthritis,  treatment  of,  in  chronic  stages, 

532 
in  early  stages,  532 
of  ankylosis,  532 
tenosynovitis,  505 
Gout,  joint  lesions  in,  535 
nodules,  535 
rheumatic,  379 
Growing  pains,  375 
Gunstock  deformity,  499 
Gymnastics,  5,  120,  294 

for  round  shoulders,  274 

H. 

Habitual  deformities,  19 
Hallux  metatarsus,  833 
rigidus,  832 
valgus,  37,  830 
varus,  832 
Hammer-toe,  37,  828 
Hamstrings,  tenotomy  of,  184,  188 
Harelip,  5 

Heat  in  treatment  of  deformity,  129 
Heel,  painful,  834 
Hemiplegia,  infantile,  649 
spastica  cerebralis,  649 
spastica  infantilis,  649 
Hemophilia,  joint  lesions  in,  536 
Hereditary  ataxia,  684 

ataxic  paraplegia,  6S4 
Heredity,  influence  of,  in  tuberculous  joint  disease,  60 

theory  of,  15,  766,  S40 
Hernia  of  lung,  289 
Hey's  internal  derangement,  4S4 
Hip,  dislocation  of,  congenital,  286,  838 
spontaneous,  402 
malignant  disease  of,  382 
Hip-joint  disease,  301 

abscess  in,  311,  317,  318 
absorption  of,  359 
acetabular,  31S 
arthritic,  318 
aspiration  of,  359 
femoral,  318 
pointing  of,  318 
residual,  317,  340 
rupture  of,  359 
treatment  for,  359 
varieties  of,  318 
acetabular  origin  of,  305,  30S 
acetabular  variety  of,  30S,  315,  339 
acute  tubercular,  310 

causes  of  death  in,  311 
osteitic  type  of,  310 
synovial  type  of,  310 
Adams'  operation  for,  363,  364 
age  in,  302 

American  method  of  treating,  353 
amputation  in,  371 

indications  for,  371 
mortality  from,  392 
amyloid  degeneration  in,  323 
ankylosis  in,  309,  311,  325,  352 
appetite  in,  317 
arthritic  variety  of,  315,  339 
aspiration  of  joint  fluid  in,  367 
atrophy  in,  311,  313,  316,  328 
attitude  in,  98,  331 

stage  of  apparent  lengthening,  314,  315 
stage  of  onset,  313 
stage  of  real  shortening,  320,  321 
bilateral,  302,  324 

treatment  of,  372 


928 


INDEX. 


Hip-joint  disease,  Billroth's  tenotomy  in,  360 
brisement  force  in,  361 
Buck  extension  in,  344 
capsular  contraction  in,  321 
caries  necrotica  in,  307 
caries  sicca  in,  30S,  317 
cartilaginous  origin  of,  305 
causes  of  death  in,  311,  323,  341 
chronic  tubercular,  311 
chronic  ulcerative,  310,  311 
circumcision  in,  304 
conservative  treatment  of,  344 
convalescent  protective  splint,  358 
definition  of,  301 
deformity  in,  310,  311,  325,  360 
diagnosis,  325 

anesthesia  in,  313,  315,  327 
lordosis,  328 
pelvic  fistulas,  320 
differential  diagnosis,  335 

congenital  dislocation,  337 
hysteric  affections,  33S 
infantile  spinal  paralysis,  337 
knee-joint  chsease,  309 
lumbar  Pott's  disease,  336 
muscular  rheumatism,  335 
night  terrors  and  night  cries,  317 
of  the  atrophy,  314 
periarthritis,  337 
relapse  and  residual  abscess,  340 
rheumatism,  309,  335 
sacro-iliac  disease,  338 
sarcoma  of  the  hip,  337 
syno\'itis  of  hip-joint,  335 
dislocation  in,  308,  320 

symptoms  of,  322,  323 
double,  302,  324 

deformity  in,  325 
duration  of,  324 
treatment,  372 
drainage  in,  368 
drilling  in,  367 

English  method  of  treating,  350 
etiology,  302 
age,  302 

exciting  causes,  302,  304 
heredity,  304 
phimosis,  303 

predisposing  causes,  302,  303,  304 
sex,  303 

traumatism,  304 
excision  in,  368 
exciting  causes  of,  302,  304 
exploratory  incision  in,  368 
extension  tray  in,  349 
false  joints  in,  361 
femoral  variety,  315,  339 
fixation  in,  350,  352 
frequency  of,  301 
Gant's  operation  for,  363,  365 
general  condition  in,  314,  320 
gouttiere  de  Bonnet,  349 
heredity  in,  304 
hygiene  in,  344 
in  adiJt,  323 

incision  of  the  joint  in,  367 
incubation,  period  of,  303 
initial  lesion  of,  305 
joint  crepitation  in,  320 
Judson  brace  for,  356 
Kingsley's  method  of  estimating  flexion  in, 

333 
kyphosis  in,  325 
leukocythemia  in,  317 


Hip-joint  disease,  ligamentous  origin  of,  305   306,  307 
long  traction  spUnt  for,  354 
Lovett's    method    of    estimating    extension 

and  flexion  in,   t,Ti2i 
Maunder's  operation  for,  363,  365 
mechanical  treatment  of,  344 
meningitis  in,  323 
mensuration,  316,  328,  332 
Kingsley's  method,  ^^,7, 
Lovett's  method,  ^^2, 
microscopic  pathology  of,  306 
mortality,  339,  340,  392 
Murphy's  operation  for,  361,  362 
muscle  spasm  in,  3ir,  313,  32r 
operative  treatment,  344,  360,  366 
origin  of,  305 

acetabular,  303,  308 
cartilaginous,  305 
from  psoas  abscess,  306 
from  tuberculous  adenitis,  306 
ligamentous,  305,  306,  307 
osseous,  305,  306,  307 
synovial,  305,  306 
osseous  origin  of,  305,  306,  307 
pathologic  varieties  of,  310 
pathology,  305 

initial  lesion,  305 
microscopic,  306 
phimosis  in,  303 
portable  bed  in,  349 
predisposing  causes  of,  302,  303,  304 
prognosis,  339 

effect  of  treatment  on,  339,  340 
in  hospital  practice,  339 
in  private  practice,  339 
recovery  from,  323,  339 

amount  of  deformity  after,  343 
relapses,  303,  340 
remissions  in,  325 
residual  abscess  in,  317,  340 
rupture  of  abscess  in,  359 
rupture  of  capsule  in,  310 
Sayre  extension  in,  344 
Sayre  long  splint  in,  354,  355 
scissor-leg  deformity  in,  325 
self-repair  in,  309 
sex  in,  303 

shortening,  measurement  for,  316 
side  affected,  301 
sinuses  in,  320 

spontaneous  absorption  of  abscess  in, 359 
stage  of  apparent  lengthening,  314 
abscess,  317,  318 
appetite,  317 
attitude,  314,  315 
atrophy,  316 
flattening  of  buttock,  316 
general  condition  in,  320 
grating,  320 
induration,  315 
joint  crepitation,  320 
lameness,  314 
leukocythemia,  317 
limitation  of  motion,  315 
night  cry,  316 
obliteration   of  fold   of   nates, 

316 
pam,  315 
stage  of  onset,  312 

atrophy,  313 

attitude,  313 

general  condition,  314 

glandular  enlargement,  314 

induration,  312 


INDEX. 


929 


Hip-joint  disease,  stage  of  onset,  lameness,  312 
limitation  of  motion,  313 
pain,  312 
stage  of  real  shortening,  320 
attitude,  320,  321 
lengthening,  322 
limitation  of  motion,  3  2 1 
night  cries,  320 
pain,  320 
shortening,  322 
temperature,  321 
stages  of,  309 
stretcher  splint  in,  349 
suppuration  in,  310,311,339,334,343 
symptoms,  309 

abscess,  311,  317,  318 

amelioration  of,  323 

anorexia,  317 

atrophy,  311,  313,  316,  328 

attitude,  313,  314,  315,  320,  321,  331 

deformity,  310,  311,  325 

diagnostic,  325 

edema,  311 

emaciation,  311 

fiatteningof  buttock,  316,  32S 

fluctuation,  310 

glandular  enlargement,  314 

grating,  320 

induration,   311,  312,  315 

joint  crepitation,  320 

lameness,  312,  314,  331 

lengthening,   322 

leukocythemia,  317 

limitation  of  motion,  313,  315,  321,  326 

limp,  312 

muscle  spasm,  311,313,321 

night  cries,  311,  316,  320 

obliteration  of  fold  of  nates,  316,  328 

of  acute  tubercular  form,   310,  311 

of  chronic  tubercular  form,  311 

of  chronic  ulcerative  form,  311 

of  dislocation  in,  322,  323 

of  double  type,  324 

of  stage  of  apparent  lengthening,  314 

of  stage  of  onset,  312 

of  stage  of  real  shortening,  320 

pain,   310,  311,  312,  315,   320,  334 

remission  of,  309,  325 

shortening,  311,  322 

swelUng,  311,  334 

temperature,  310,  311,  321 

tenderness,  311,  320 
synonyms,  301 
synovial  effusion  in,  310 
Taylor  splint  for,  354,  355,  357 
Thomas  hip  splint,  350,  357 
tilting  of  pelvis  in,  315,  331 
traction  splints,  354 
traumatism,  in  causation  of,  304 
traveling  acetabulum  in,  308,  322 
treatment,  344 

American  method  of,  353 

amputation,  371 

aspiration  of  joint  fluid,  367 

brisement  force,  361 

Buck  extension.  344 

conservative,  344 

convalescent  protective  splint,  358 

counterextension,  353 

drainage,  368 

drilling,  367 

English  method  of,  350 

erasion,  368 

excision,  3  68 
60 


Hip-joint  disease,  treatment,  exploratory  incision, 

extension  tray,  349 

fixation  method,  350,  352 

gouttiere  de  Bonnet,  349 

hygienic,  344 

incision  of  the  joint,  367 

Judson  brace,  356 

long  traction  splint,  354,  355 

mechanical,  344 

myotomy,  360 

of  abscesses,  359 

of  complications,  358 

of  deformity,  360 

of  double  variety,  372 

of  night  cries,  358 

of  sinuses,  359 

operative,  344,  360,  366 

osteoclasis,  361 

osteotomy,  361 

portable  bed,  349 

recimibency  with  extension,  344 

Sayre  extension,  344 

Sayre  long  splint,  354,  355 

stretcher  splint,  349 

Taylor  splint,  354,  35s,  357 

tenotomy,  360 

Thomas  hip  spUnt,  350,  357 

time  required  for,  342 

traction  method  of,  353 

traction  splints,  354 

trephining,  367 

Willard's  hip  splint,  350 

wire  cuirass,  349 
tuberculosis  in,  309,  323 
Volkmann's  operation  for,  363 
Willard's  operation  for,  368 
worm-eaten  appearance  in,  308 
lues  of,  379 

neuropathic  affections  of,  387 
Hippocrates,  angina  of,  5 
History  of  orthopedic  surgery,  2 

American,  12 
Hoffa's  classification  of  contractures,  50 

machine,  123 
Hohlfuss,  805 
Hollow  back,  273 
Hot-air  apparatus,  129 
Housemaid's  knee,  448 
Huhnerbrust,  291 
Hydatid  cyst  of  hip,  405 
Hydrocephalus,  16 
Hydrops,  articular,  515 

tuberculous,  310 
H)'peresthetic  spine,  244 

Hypertrophic  pulmonarj'  osteoarthropathy,  278 
Hypertrophy  of  fingers  and  toes,  891 

of  synovial  villi,  514 
Hypospadias,  16 

Hysteria  in  neuromimesis,  699,  701 
Hysteric  joint,  49 
paraplegia,  244 
spine,  244  f 

Idiopathic  intermittent  joint  hydrops,  515 
Hiac  abscess,  98,  232 
Iliopsoas  bursitis,  405 
Impressions  of  feet,  105 
Improved  trolley  delineator,  567 
Increased  number  of  ribs,  291 
Incurvation  of  neck  of  femur,  384 
Infantile  osteomalacia,  38 
scorbutus,  275,  538 


930 


INDEX. 


Infantile  scurvy,  538 

spinal  paralysis,  603 

anterior  poliomyelitis  in,  603,  607 
attitude  in,  97 
causes  of,  605 
deformities  from,  617 
deformities  of  lower  extremities  in,  619 
deformities  of  trunk  in,  621 
deformities  of  upper  extremities  in,  618 
diagnosis  of,  621 

differential,  625 
electric  reaction  of  muscles,  622 
etiology  of,  603 
forms  of,  616 
pathology  of,  608 
prognosis  of,  627 
prophylaxis  of,  118,  629 
stages  of,  612 
symptoms  of,  612 
synonyms  of,  603 
treatment  of,  629 
;  electricity  in,  631 

massage  in,  630 
mechanical,  632 
medical,  629 
operative,  638 

amputation,  646 
aponeurotomy,  645 
arthrodesis,  646 
excision,  645 

forcible  straightening,  645 
myotomy,  645 
neural  anastomosis,  645 
osteoclasis,  646 
osteotomy,  646 
tendon-shortening,  641 
tenotomy,  639 

transplantation  of  tendons,  642 
Infarct  of  bone,  71 
Infectious  osteomyelitis,  517 
Infiltration,  tuberculous,  211 

Influence  of  heredity  in  tuberculous  joint  disease,  60 
of  naso-pharyngeal   affections  in   deformities   of 

thorax,  293 
of  spondylolisthesis  in  labor,  289 
Inherited  syphilitic  joint  disease,  525 
In-knee,  727 

Inoculation  with  tubercle  bacilli,  65 
Inspection  in  diagnosing  deformity,  98 
Intermittent  joint  hydrops,  515 
Internal  crural  abscess,  319 

lumbar  abscess,  232 
Intra-articular  inflammation,  529 

tenderness,  417 
Intrauterine  pressure,  theory  of,  15,  766,  841 
Introduction,  general,  i 
Iodoform  emulsion,  85,  265 
Irons,  bending,  139 
Ischemia,  19 
Isteria  mimetica,  699 


Jacket,  leather,  163 

plaster-of-Paris,  12,  157,  253 
Jerk-finger,  893 
Joint,  abscess,  74 

contractures,  56 

disease,  prevention  of  deformity  in,  118 
in  neuromimesis,  700 
non-tuberculous,  512 
scrofulous,  59 
strumous,  59 
tuberculous,  SQ 


Joint  hydrops,  intermittent   51 S 
measure,  332 
mice,  452 
Joints,  artificial,  361 

neuropathic  affections  of,  703 
varieties  of,  139 
Judson  brace,  356 
Jury-mast,  255 

K. 

Kahnbrust,  291 

Kingsley's  method  of  estimating  flexion  in  hip-joint 

disease,  333 
Kinkung  der  Wirbelsaule,  207 
Klumpfuss,  760 
Kliunphand,  883 
Knee,  congenital  dislocation  of,  877 

scrofulous  disease  of,  407 

snapping,  460 
Knee-cap,  elastic,  455,  459 
Knee-joint,  disease,  407 

loose  bodies  in,  444 
Knickbein,  727 

Knickung  der  Wirbelsaule,  207 
Kniebohrer,  727 
Knieng,  727 
Knock-knee,  29,  727 

acquired,  727 

atonic,  728 

arthritic,  729 

bilateral,  731 

diagnosis  of,  732 

occurrence  of,  727 

paralytic,  728 

pathology  of,  730 

prognosis  of,  732 

rachitic,  727 

symptoms  of,  730 

synonyms  of,  727 

theories  of,  729 

traumatic,  729 

treatment  of,  732 
hygienic,  732 
mechanical,  733 
operative,  734 
Kocher's  method  for  resection  of  ankle-joint,  468 
Kyllosis,  760 
Kyphosis,  207,  272,  294 

adolescent,  272 

definition  of,  272 

muscular,  274 

of  Pott's  disease,  211,  243 

rachitic,  275 

round  shoulders  in,  272 

synonyms  for,  272 

L. 

Lateral  curvature  of  the  spine,  539 
acquired,  543 
age  in,  540,  543 
American  position  in,  547 
astigmatism  in,  574 
attitude  of  fatigue  in,  547 
attitude  of  rest  in,  547 
back  knee  in,  553 

Beely's  correcting  machine  for,  595 
best  standing  position  in,  578,  580 
best  voluntary  position  in,  5  78 
braces  for,  591,  592 
breathing  in,  580 
cervical,  560,  590 
clinical  history  of,  557  , 


INDEX. 


931 


Lateral  curvature  of  the  spine,  compensatory  curves 

in.  559 

compression  curves  in,  559 

congenital,  543 

correcting  machines  for,  595 
Beely's,  595 
Lovett's,  596 

definition  of,  539 

deformity  in,  558 
of  pelvis,  552 
of  ribs,  552 
of  thorax,  552 
of  vertebras,  551 

degree  of  deformity  in,  5  68 

development  of  lower  extremities  in,  5  79 

diagnosis,  562 

if  due  to  empyema,  569 

if  due  to  neuromuscular  change,  5  69 

of  habit  scoliosis,  568 

of  paralytic  scoliosis,  569 

of  racliitic  scoliosis,  568 

of  the  three  stages  in,  568 

of  traumatic  scoliosis,  569 

differential  diagnosis  in,  569 

lateral  bending   of  the   spine, 

569 
lateral  curvature  from   neuro- 
muscular change,  569 
lateral  deviation  of    the   spin- 
ous processes,  569 
lumbago,  570 
Pott's  disease,  570 
rickets  of  spine,  570 
sacro-iliac  disease,  570 
sarcoma  of  spine,  570 
sciatica,  570 
early  symptoms  of,  557 
effects  of,  553 

on  parturient  women,  571 
etiology  of,  543 
age  in,  543 
astigmatism  in,  574 
diseases,  548 
heredity  in,  543 
"  exciting  causes,  544 

habits  in,  547 
hysteria  in,  549 
muscular  debility  in,  543,  544 
neuromuscular  change  in,  549 
occupation,  551 
predisposing  causes,  543 
professions,  547 
rickets,  544 

shortening  of  one  leg,  547 
theories  regarding,  555 
traumatism  in,  549 
vocations,  547 
exciting  causes  of,  544 
exercises  for,  575,  580 

after  deformity  has  been  corrected, 

590,  S9I 
bilateral,  591 

during  menstrual  period,  579 
fall  out  standing  position,  584 
for  inequality  of  lower  extremities, 

587 
frequency  of,  579 
in  prone  position,  5S9 
in  summer,  579 
key-note  position  in,  578,  580 
on  the  plinth,  589 
salute,  5S6 

swimming  movements,  586 
first  stage  of,  562 


Lateral  curvature  of  the  spine,  forms  of,  539,  541, 
544 
forms  of,  diagnosis  of,  5  68 
\  relative  frequency  of,  541,  542 

frequency  of,  539 

among  boys  and  girls,  $39 
among  school-children,  540 
among  the  enlightened,  541 
at  different  ages,  540 
from  wry-neck,  560 
gait  in,  558 

gymnastic  exercises  for,  575,  580 
habit  scoliosis,  544 
heredity  in,  543 
high  hip  in,  558 
hyperextension  of  elbow  in,  553 
hysteric,  549 

in  infantile  paralysis,  549 
in  pelvic  tumors,  549 
in  pleural  pneumonia,  548 
in  sacro-iliac  disease,  549 
initial  stage  of,  562 
keynote  position  in,  578,  580 

for  spiral  movements,  579 
Lovett's  correcting  machine  for,  596 
lumbar,  558 

mechanical  correction  of,  593 
Lorenz  swing,  594 
Redard  apparatus,  594 
Shaw  couch,  594 
mensuration  and  recording  methods  in, 
563 
Bradford's  scoliosometer, 

566 
cystometer,  564 
freehand  drawing,  564 
improved  trolley  delinea- 
tor, 567 
lead  measure,  564 
photography,  564 
plaster  casts,  564 
rod  scoliosometer,  568 
Sargent's  charts,  565 
screen   photography,    565 
SpeUissy's  uniform  photo- 
graphic method,  566 
method  of  examining  for,  562 
pathologic,  548 
pathology  of,  549,  551 

of  the  intervertebral  disks,  552 
of  the  ligaments,  552,  553 
of  the  muscles,  553 
of  the  ribs,  552 
of  the  vertebras,  551 
of  the  viscera,  553 
phthisis  in,  553 
position  of  shoulders  in,  559 
pressure  osteitis  from,  551 
primary  curve  in,  559 
professional,  547 
prognosis  in,  570 
progress  in,  570 
prophylaxis  of,  571 

correct  attitude  in  sitting  571 
correct  attitude  in  writing,  574 
in  school-children,  571 
light,  57S 

school  furniture,  571 
resection  of  ribs  for,  602 
rotation  of  vertebras  in,  551 
second  stage  of,  562 
secondary  curves  in,  559 
sex  in,  539,  540,  543 
stage  of  arrest  in,  562 


932 


INDEX. 


Lateral  curvature  of  the  spine,  stage  of  development 
in,  562 

stages  of,  562 

stages  of  deformity  in,  568 

static,  547 

s'jperstitious  ideas  concerning,  562 

symptomatolog)',  557,  562 
of  primary  cervical,  560 
of  primar)'  dorsal,  559 
of  primary  lumbar,  558 
of  secondary  dorsal,  559 

synonyms  for,  539 

tenotomy  in,  602 

third  stage  of,  562 

torsion  of  vertebras  in,  551 

traumatic,  549 

treatment,  575 

breathing,  5S0 

by  braces,  591,  592 

correcting  machines,  595 

correction  of  rotation,  579,  601 

for  inequality  of  lower  extremities, 

587 
gymnastic  exercises,  575,  580 
heavj'  gymnastics,  591 
keynote  position,  578,  579,  580 
local  anesthetics  in,  601 
massage,  579 

mechanical  correction,  593 
modified  Shaffer  brace,  592 
myotomy,  602 
of  cervical  scoliosis,  590 
of  first  group  of  cases,  576,  577 
of  left  dorsal  scoliosis,  588 
of  left  lumbar  scoliosis,  587 
of  lumbar  scoliosis,  590 
of  right  dorsal  scoliosis,  580 
of    second    group    of    cases,    576, 

592 
of     third    group     of     cases,     576, 

601 
prophylactic,  571 
resection  of  ribs,  602 
self-suspension,  575,  576 
tenotomy  in,  602 
vocational,  547 
Young's    modified    Shaffer    brace    for, 

592    593 

deviation  of  toes,  830 
Law  of  transformation,  20 

Wolff's,  20,  23 
Lead  tape,  98,  130,  564 
Leather  corsets,  255 

jacket,  163 
Leather)'  crepitation,  515 
Leg  braces,  140,  734,  744,  745 
Leukocythemia  in  hip-joint  disease,  317 
L'homme  moyen,  711 
Limbs,  artificial,  164 
Line,  Roser-Nelaton,  332J 
Linear  osteotomy,  igg 
Lipoma  of  hip,  405 
Liquefaction  necrosis,  1 

Lister's  method  for  excision  of  wrist-joint,  502 
Lobster  claw,  885 
Locking  of  knee-joint,  455 
Lock-joints,  139  \ 

Longitudinal  osteotomy,  200         S% 
Loose  bodies  in  elbow-joint,  497     ' 
in  knee-joint,  444,  452 

shoulder-joint,  481 
Lordose,  272  -v 

Lordosis,  286 
Lordotische  skoliose,  286 


> 


Lorenz  method  of   reduction  for  congenital  disloca- 
tion of  hip,  858 

swing,  594 
Lo  Strambo,  739 
Lovett's  rule,  333 
Lues  of  hip-joint,  379 
Lumbar  abscess,  97,  231,  232,  264,  265 

caries,  attitude  in,  220 

fascia,  230 
Lung,  hernia  of,  289 
Lupus,  in  wrist-joint  disease,  501 
Lymphoid  cells,  67,  68 

M. 

Machine,  Beely,  123 

Goldthwait,  172 

Hoffa,  123 

Weigel-Hoffa,  123 

Zander,  122 
Machines,  scoliosis,  123 
Main  bot,  883 
Mai  de  Pott,  207 

Mai  sacroiliac,  295  ^ 

Maladie  Dupuytren,  892 
MaUgnant  disease  of  spine,  278 

of  hip,  3S2 
Malo  di  Boyer,  295 
Malo  di  Pott,  207 
Malocoxario,  301 
Malum  cox«  senilis,  379 

senile,  379 
Manual  correction  of  deformity,  171 
Many-tailed  bandages,  141,  142 
Marsh  apparatus,  455 
Massage,  2,  123,  286,  630,  866 

movements,  124 
Maternal  impressions,  theory  of,  16,  766 
Maw's  moleskin  plaster,  141,  356 
Measure,  joint,  332 
Mechanical  correction  of  deformity,  171 

gymnastics,  122 

pressure,  theor}-  of,  15,  766,  841 

walking  shoe,  193 
Mediastinal  abscess,  229 
Medullization,   210 
MeduUo-arthritis,  301 
Aleningomyelitis,   236 
Mensuration  in  diagnosing  deformity,  98 
Mental  effects  of  deformity,  96 
Metastasis  in  sarcoma  of  spine,  279 
Metatarsalgia,  823 
Metatarsals,  tuberculosis  of,  471 
Metatarsectomy,  471 
Method,  Adams',  for  examining  back,  243 

American,  for  treating  joint  disease,  12,  353 

Anderson's,  for  tenotomy,  176 

Bayer's,  for  tenotomy,  360 

Biliroth's,  for  tenotomy,  177 

Hoffa's,  for  reduction  of  congenital  dislocation  of 
hip,  870 

Kingsley's,    for   estimating   flexion   in    hip-joint 
disease,  ^^^ 

Kocher's,  for  resection  of  ankle-joint,  46S 

Lister's,  for  excision  of  wrist-joint,  502 

Lorenz's,  for  reduction  of  congenital  dislocation 
of  hip,  S58 

Paci's,  for  reduction  of  congenital  dislocation  of 
hip,  857 

Rugh's,  for  tenotomy,  177 

Spellissy's  uniform  photographic,   of  scoliosom- 
etr)',  566 

Studsgard's,  for  excision  of  wrist-joint,  503 

Taylor's,  for  reducing  deformity,  357 


INDEX. 


933 


Mice,  joint,  452 

Mieliti  anteriora,  603 

Military  brace,  for  round  shoulders,  273 

gymnastics,  120 
Miller's  chair,  573 
Mixed  infection,  79 
Models,  Braatz,  102 

wax,  no 
Moleskin  plaster,  Maw's,  141,  356 
Monoarticular  rheumatism,  534 
Mononuclear  cells,  67 
Monstrosities,  2S9 
Morbo-coxario,  301 
Morbus  anglicus,  715 

coxa,  301 

coxarius,  301 

puerilis,  715 

senilis,  379 
Morton  corset,  272 
Multinuclear  cells,  67 
Multiple  exostoses,  43 
Muscles,  contractures  of,  50 

pectoral,  absence  of,  290 

rubber,  11,  141 
Muscular  atrophy,  progressive,  676 

dystrophy,  43 

kyphosis,  274 

from  spinal  meningitis,  274 

tissue,  rupture  of,  913 
Musculo-tendinous  anastomosis,  176 
Myelitis,  compression,  215,  216,  236 

meningo-,  236 

of  anterior  horns,  603 

osteo-,  43 
Myogenic  paralysis,  603 
Myotomy,  196,  4S5,  777 

Billroth's,  360 

N. 

Naso-pharyngeal  affections,  influence   of,  in^deform- 

ities  of  thorax,  273 
Necrosis,  coagulation,  67 

in  infectious  osteomyelitis,  517 

liquefaction,  68 
Necrotica,  caries,  211 
Nerve  anastomosis,  197 

grafting,  197 

suturing,  197 

transplantation,  197 
Neuralgia,  plantar,  837 
Neurasthenic  spine,  244 
Neurectomy,  196 

of  spinal  accessor}'  nerve,  196 
Neuromimesi,  699 
Neuromimesis,  699 
Neuromimetic  spine,  244 
Neuromyositis,  50 

Neuropathic  affections  of  joints,  703 
of  hip-joint,  381 

lesions,  in  deformity,  43 
Neuroplasty,  197 
Neurorrhaphy,  197 
Neurotomy,  197 

Nichol's  operation  for  infectious  osteomyelitis,  519 
Night  cries  in  ankle-joint  disease,  464 
in  hip-joint  disease,  316 
in  knee-joint  disease,  417 
in  Pott's  disease,  221 

"terrors,"  317 
Nineteenth  century,  period  of  orthopedic  history,  6 
Nodosity  of  joints,  751 
Nodular  rheumatism,  379 
Nodules,  gout,  535 


Nontuberculous  disease  of  ankle-joint,  470 

of  elbow-joint,  495 

of  hip-joint.  373 

of  knee-joint,  440 

of  shoulder-joint,  478 

of  wrist-joint,  505 
joint  disease,  512 

traumatic  etiology  of   44,  512 
Normal  curves  of  spine,  549,  550 
Novure,  715 

O. 

O-Bein,  739 

ObUque  osteotomy,  200 

Obstetric  dislocations,  842 

paralysis,  484 
Obstructed  respiration,  291 
Olecranon  bursitis,  499 
Origin  of  popliteal  cysts,  451 
Orthopedic  apparatus,  141 

operations,  171,  176 

surgery,  definition  of,  i 
history  of,  2 

in  America,  12 
in  England,  10 

tools,  139 
Orthopedy,  i 
Osseous  ankylosis,  56 

focus,  66 

terminations  of,    71 
absorption,  71 

extra-articular  perforation,  72 
intra-articular  perforation,  73 

theory,  16,  768,  884 

type  of  elbow-disease,  490 
Osteitis,  38 

chronic  articular,  of  hip,  301 
tubercular,  of  knee,  407 

deformans,  750 
syphilitica,  747 

destructive,  210 

of  the  spine,  207 

osteoplastic,  216,  309 

rarefying,  212 
Osteoarthritis,  379 
Osteoarthropathy,  hypertrophic  pulmonar)',  278 

secondary  hypertrophic,  750 
Osteochondritis  dissecans,  4S3,  497 

syphilitic,  526 
Osteoclasis,  11,  172,  361,  646,  739,  744,  745 

rapid,  174 

technic  of,  174 
Osteoclasts,  173,  175,  739 
Osteomalacia,  38,  749 
Osteomyelitis,  43,  44 

tuberculous,  59 

vertebral,  244,  277 
Osteo-periostite,  407 

tuberculose  chroniquej  59 
Osteoperiostitis,  syphihtic,  526 
Osteoplastic  osteitis,  2i|5;  309 
Osteoporosis,  26 
Osteotomes,  199,  363,  736,  737 
Osteotomy,   199,   361?,   646,   735,   744,   745,  877,   919 

cuneiform,  203    ' 

linear,  igg 

longitudinal,  200 

oblique,  200 

subcutaneous,  10 

technic  of,  199 

vertical,  200 
Ostitis  ereditaria  sifilitica,  747 

hereditaria  sifilitica,  747 


934 


INDEX. 


Ostitis,  tuberculous,  59 
Outline  measurements,  130 
Overlapping  toe,  37 


Pachymeningitis,  215,  236 
Painful  heel,  83S 

points  of  Valleix,  298 
Pains,  growing,  375 
Palate,  cleft,  16 

Palpitation  of  heart,  in  pigeon  breast,  292 
Palsy,  cerebral,  647 

attitude  in,  98 
infantile  spinal,  attitude  in,  97 
peripheral,  686 
pressure,   686 
Pan-articular  inflammation,  529 
Paper  splints,  161 
Paquelin  cautery,  368 
Paralysi  atrofica  dei  bambrici,  603 

spastica,  649 
Paralysie  atrophique  graisseuse  de  I'enfance,  603 
essentielle,  603 
infantile,  603 
spinale,  603 
Paralysis  atrofica  infantil,  603 
Paralysis  atrophica,  676 

during  dentition,  603 
infantile  spinal,  603 
in  neuromimesis,  700 
myogenic,  603 
obstetric.  484 

pseudo-hypertrophic,  43,  671 
regressive,  603 
Paralytic  lordosis,  286 
Paraplegia  dolorosa,  278,  279 
hysteric,  244 

in  Pott's  disease,  215,  216,  232,  244,  245,  266 
Paronychia,  517 
Parrott's  osteochondritis,  526 
Partial  development  of  sternum,  290 
Passive  congestion,  treatment  by,  87,  479,  494 
Patella,  dislocation  of,  456 
floating,  443,  444,  513 
rudimentary,  459 
Patellar  tendon,  elongation  of,  461 

rupture  of,  461 
Pathologic  lordosis,  286 
Patizambo,   739 

Pectoral  muscles,  absence  of,  290 
Pectus  carinatum,  291 

excavatum,  291 
Pedagogic  gymnastics,  120 
Pelmatograms,  106 
Pelvimeter,   105 
Pelvis,  spondylolisthetic,  214 
Pendulum  apparatus,   123 
Percussion,   124 

Periarthritis  humoroscapularis,  480 
Periarticular  abscess,   524 

Pericarditis  from  acute  articular  rheumatism,  534 
Pericecal  abscess,  245 
Period,  continental,  5 
early  English,  5 
nineteenth  century,  6 
pre-continental,  2 
Periosteitis,  syphilitic,  44 
Peronei,  tenotomy  of,  184  j 

Perrott's  pseudoparaplegia,  2S2 
Perverted  development,  883 
Pes  contortus,  760 

planus,  792  ~>, 

Petrissage,  124 


Pferdefuss,  795 

Phelps'  combination  traction  hip  splints,  357 

conclusions  regarding  joint  ankylosis,  352,  353 
portable  bed,  349 
Phlegmon  of  knee,  446 
Photographic  screen,  109,  565 
Photographs  of  deformities,  106 
Photography  in  scoliosometry,  564 
Physiognomy  in  deformity,  96 
Physiologic  cubitus  valgus,  498 
Pie  cavo,  805 
piano,  792 
truncado,  760 
Pied  bot,  760 
creux,  805 

plat  valgus  acquis  de  I'adolescence,  792 
Piede  di  cavo,  805 

da  piannezza,  792 
spianato,  792 
torto,  760 
Pierna  Zamba,  739 
Pigeon  breast,  227,  2S9,  291,  722 
Pins,  Wyeth's,  372 
Plantalgia,  837 
Plantar  fascia,  division  of,  183 
Plaster,  casts,  no 

in  scoliosometry,  564 
Maw's  moleskin,  141,  356 
Shiver  swansdown,  141,  356 
Plaster-of-Paris  bandages,  861,  863 
jackets,   12,  157,  254 

disadvantages  of,  254 
portable  bed,  Phelps',  142,  349 
sphnts,  142,  425 
Plattfuss,  790 

Pleurisy  from  acute  articular  rheumatism,  534 
I   Podagra,  535 
I   Pododynia,  837 
Pointing  of  abscess,  2  28 
Poitrine  de  pigeon,  291 

en  carfene,  291 
Poliomieliti,  603 
Poliomyelitis  anterior,  603 
Polyarticular  gonorrheal  arthritis,  528,  529 
rheumatism,  533 
serous  effusion,  530 
tuberculosis,  63 
Polydactylism,  S84 
Popliteal  bursee,  451 

cysts,  451 
Position  hanche,  282,  297 

Roser,  264 
Posterior  curvature,  207 

deformity.  272 
Postpharyngeal  abscess,  229 
Pott's  cUsease  of  the  spine,  207 

abscess  in,  214,  245 
cervical,  228 
drainage  of,  265 
evacuation  of,  263 
frequency  of,  227 
gluteal,  232 

hyperdjstention  of,  263 
iliac,  232 
incision  of,  264 
iodoform  injection,  265 
lumbar,  231,  264,  265 
mediastinal,  229 
pointing  of,  22S 
prognosis  of,  24S 
psoas,  220,  230,  246,  264,  265 
residual,  227,  248 
retropharyngeal,  229,  263 
rupture  of,  248 


"^ 


INDEX. 


935 


Pott's  disease  of  the  spine,  abscess  in,  spinal,  table  of, 
232 

symptoms  of,  228 
Adams'  method  of  examination  for,  243 
angular  deformity,  211,  222 
attitude  in,  219 
caries  necrotica,  211 

sicca,  214 
causes  of  death  in,  248,  250 
compensatory  distortions  in,  215 
compression  myelitis  in,  215,  216.  236 
cystitis  in,  236 
definition  of,  207 
deformity  in,  211,  222 

scissor-leg,  236 
diagnosis  of,  236 

errors  in,  221 
differential  diagnosis,  243 

from   hip-joint    disease,    246, 

247.  336 
from  infantile  paralysis,  247 
from  sacro-iliac   disease,   246, 

247 
from  sarcoma  of  spine,  280,  281 
of  the  abscess,  245 
of  the  deformity,  243 
of  the  paraplegia,  244 
duration,  236 
empyema  in,  229 
etiology,  20S 

age,  208 

exanthemata,  210 

heredity,  209 

sex,  2og 

traumatism,  210 

whooping-cough,  210 
frequency  of,  207 
funnel  breast  in,  291 
history  of,  207 
kyphosis,  211,  243 
localization  of,  20S 
mortahty  in,  248 
osteoplastic  osteitis  of,  216 
paralysis  in,  216 
paraplegia  of,  215,   216,  232,  244,  248, 

266 
pathology,  2ro 

medullization,  210 

of  abscess,  214 

of  membranes  and  cord,  215 

primary  lesion,  210,  212 
pigeon  breast  in,  292 
priapism  in,  236 
prognosis,  247 

influence  of  abscess  on,  248 

under  treatment,  247,  250 
progress  of,  247 
relapses  in,  250 
relative  frequency  of,  207 
Roser  position  in,  264 
scoliosis  in,  213 
scrofulosis  in,  209 
symptomatology,  216 

abscess,  228 

attitude,  219 

breath  catch,  221 

deformity,  211,  222,  236 

grunting,  221,  222 

malaise,  216 

muscular  spasm,  219 

night  cries,  221 

pain,  220,  221 

paraplegia,  232 

rigidity  of  spine,  219,  230 


Pott's  disease  of  the  spine,  symptomatology,  tempera- 
ture, 228 
synonyms,  207 
treatment,  251 

chin  rest,  255,  261 
constitutional,  119,  251 
forcible  correction,  269,  270 
hygienic,  119,  251 
jury  mast,  255 
laminectomy,  270,  271 
leather  corsets,  255 
mechanical,  253  , 

of  abscess,  263,  264 
of  the  deformity,  255 
of  the  necrosis,  262 
of  the  paraplegia,  266 
operative,  263 
plaster-of-Paris  jacket,  253 
recumbency,  251 
spine  braces,  255,  256 
suspension,  253 
wooden  corsets,  255 
tubercular  diathesis  in,  209 
tuberculosis  in,  210 
Pre-continental  period  in  orthopedic  history,  a 
Predisposition,  acquired,  61 
inherited,  60 
local,  61 
static,  62 
Prenatal  disease,  theory  of,  16,  767,  843 
Prepatellar  bursa,  description  of,  447 

bursitis,  447 
Pressure,  intrauterine,  theory  of,  15,  766,  841 
mechanical,  theory  of,  15,  766,  841 
theory,  20 
Pretibial  bursas,  description  of,  449 

bursitis,  449 
Priaprism  in  Pott's  disease,  236 
Primary  curves  of  spine,  550 
Progressive  muscular  atrophy,  676 
attitude  in,  98 
diagnosis  of,  6S3 
etiology  of,  676 
forms  of,  676 
lordosis  in,  2S6,  683 
pathology  of,  677 
prognosis  of,  683 
symptomatology,  678 
synonyms  for,  676 
treatment  of,   683 
Progressive  Muskelatrophie,  676 

Muskellahmung,  676 
Pronation  of  feet,  826 
Pseudo-hypertrophic  paralysis,  43,  671 
Pseudo-muscular  palsy,  lordosis  in,  286 
Pseudo-paraplegia  of  Perrott,  2S2 
Psoas  abscess,  220,  230,  246,  264,  265,  306 

muscle,  sheath  of,  230 
Pubic  abscess,  319 
Purulent  tenosynovitis  of  wrist,  506 


Quadriceps  extensor  tendon,  rupture  of,  461 

R. 

Rachischisis,  290 

Rachitic  deformity,  37,  no,  291,  721 

genu  valgum,  29,  727 

genu  varum,  739 

kyphosis,  275 

rosary,  292,  721 
Rachitide,  715 


r^ 


/^ 


936 


INDEX. 


Rachitis,  714 

Rachitisme,  715 

Rack  and  pin  extension  joint,  139 

Radiotherapy  in  tuberculous  arthritis,  87 

Railway  spine,  275 

Rapid  osteoclasis,  174 

Raquitis,  715 

Rarefying  osteitis,  212 

Ray  theory,  19 

Recurrent  dislocation  of  shoulder-joint,  482 

Reel  foot,  760 

Regressive  paralysis,  603 

Resection,  articular,  206 

for  ankylosis,  206,  919 
for  congenital  dislocation  of  hip,  873 
for  diastasis,  909 
of  ankle-joint,  468,  471 
of  elbow-joint,  495 
of  shoulder-joint,  478 
Residual  abscess,  227,  248,  319 
Respiration,  obstructed,  291 
Retro-calcaneal  bursitis,  834 
Retropharyngeal  abscess,  229,  263 
Rheumatic  gout,  379 
Rheumatism,  acute  articular,  533 
monoarticular,  534 
nodular,  379 
of  spine,  756 
polyarticular,  533 
Rheumatisme  chronique  primitif,  75  r 
Rheumatoid  arthritis,  244,  379,  533 
Rhizomelic  spondylosis,  281,  753 
Ribs,  absence  of,  291 

increased  number  of,  291 
Rice  bodies,  19 

in  tenosynovitis  of  wrist,  506 
Rickets,  37,  715 
adolescent,  718 
bow-legs  in,  739 
complications,  725 
congenital,  717 
cubitus  valgus  in,  498 
deformation,  721 

deformity  in,  37,  no,  289,  291,  721 
etiology  of,  715 
fetal,  275,  717 
funnel  chest  in,  291 
incubation,  720 
infantile,  7t8 
intrauterine,  717 
knock-knee  in,  29,  727 
naso-pharyngeal  obstructions  in,  293,  720 
pathology  of,  718 
pigeon  breast  in,  291,  722 
prognosis  of,  725 
prophylaxis,  119 
recovery,  725 
senile,  718 
symptoms  of,  720 
synonyms  for,  715 
treatment  of,  general,  7^5 
of  bow-legs,  743       '-..^ 
of  knock-knee,  732 
Rigidity,  spastic,  651 
Rod  scoliosometer,  568 
Rodella  al  interno    727 
Roideur  articulaire,  9r4 
Rolling,  124 
Rontgen  ray,  87,  109 
Rosary,  rachitic,  292  J 

Roser  position,  264  , 

Roser-Nelaton  line,  332 

Rotation  of  bodies  of  vertebrae  in  normal  spifte,  550 
in  scoliosis,  551 


Round  back,  273 

hollow  back,  273 
shoulders,  272 

gymnastic  exercises  for,  274 
in  flat  chest,  291 
types  of,  273 
Rubber  foot,  160 

muscles,  11,  141 
Rilckverbiegung  der  Wirbelsaule,  272 
Rudimentary  patella,  459 
Rugh's  tenotomy,  177 
Rule,  Lovett's,  333 
Rupture  of  biceps  muscles,  487 
of  muscular  tendons,  913 

tissue,  913 
of  patellar  tendons,  461 
of  quadriceps  extensor  tendon,  461 

S. 

Sabelbein,  739 
Sacroarthrocace,  295 
Sacro-coxalgie,  295 
Sacro-coxitis,  295 
Sacro-iliac  disease,  295 

abscess  in,  296,  297,  298 

pointing  of,  297 
causes  of  death  in,  299 
danger  of  operating,  299 
definition,  297 
diagnosis,  298 

caries  of  ilium,  298 

lumbago,  298 

lumbar  Pott's  disease,  299 

lumbo-abdominal  neuralgia,  298 

necrosis  of  ilium,  298 

psoitis,  298 

sciatica,  298 
dry  gangrenous  form,  296 
etiology,  295 

age,  29s 

exhaustion,  295 

exposure,  295 

pregnancy,  295 

sex,  295 

traumatism,  295 
moist  form,  296 
pathology,  295 
position  hanche  in,  297 
Pott's  disease  in,  295 

abscess,  296 

discharge  of  bone  per  rectum,  296 

granulation  tissue,  296 

sequestra,  296 

tuberculous  foci,  296 
prognosis,  299 

in  children,  299 

in  dry  gangrenous  variety,  299 

influenced  by  operation,  299 

in  moist  variety,  299 
scoliosis  in,  549 
suppuration  in,  297 
symptoms,  296 

elongation  of  limb,  297 

gait,  297 

lameness,  297 

local  temperature,  297 

muscular  atrophy,  297 

pain,  296 

swelling,  297 
synonyms,  295 
treatinent,  299 

apparatus  in,  300 

counterirritation,  300 


INDEX. 


Sacro-iliac  disease,  treatment,  drainage,  300 
excision,  300 
extension,  300 
hygiene,  300 
immobilization,  300 
of  abscess,  300 
of  sequestra,  300 
Van  Hook's,  300 
varieties  of,  296 
Sacrum,  displacement  of,  911 
Saddle-leg,  739 
Sarcoma  of  spine,  278 

differential  diagnosis,  280 
aneurysm,  285 
appendiceal  abscess,  282 
caries  sicca,  281 
compression  myelitis,  285 
hip-joint  disease,  284 
iliac  abscess,  283 
intraspinal  growths,  285 
lateral  curvature,  284 
lumbago,  284 
neuromimesis,  282 
osteoarthritis,  283 
perinephritic  abscess,  282 
posterior  spinal  sclerosis,  285 
Pott's  disease,  280,  281 
rickets  of  the  spine,  281 
sacro-iliac  disease,  282 
sciatica,  284 
senile  kyphosis,  283 
spina  bifida,  285 
spinal  irritation,  284 
spinal  meningitis,  285 
spinal  pachymeningitis,  285 
syphilis  of  the  spine,  283 
typhoid  spine,  283 
Sargent  apparatus,  122 
chart,  565 
system,  122 
Sayre  club-foot  shoe,  141 

suspension  apparatus,  157 
Scaphoid,  tuberculous  disease  of,  470 
Scapula,  congenital  elevation  of,  486 
Scarpa's  club-foot  shoe,  6,  141 
Schemmelbein,  727 
Schenkelhals  Verbiegungen,  3S4 
Schiefhals,  687 
Schnellendes  knee,  460 
School  furniture,  571 
gymnastics,  120 
Scissor-leg  deformity,  236   325,  388 
Scissors  gait,  390 
Scoliose,  539 
Scoliosi,  539 
Scoliosis,  27,  no,  539 
habitual,  544 
in  Pott's  disease,  213 
machines,  123,  595 
pigeon  breast  in,  291 
static,  547 
Scoliosometer,  Bradford,  566 

rod,  568 
Scoliosometry,  563,  568 

Spellissy's  uniform  photographic  method,  566 
table  of,  563 
Scorbutic  spondylitis,  275 
Scorbutus,  infantile,  275,  538 

joint  lesions  in,  538 
Scrofulose  caries,  59,  407 
Scrofulose  Gelenkentziindung,  59,  407 
Scrofulous  diathesis,  209 
disease  of  knee,  407 
joint  disease,  59 


Scurvy,  infantile,  538 
Secondary  curves  of  spine,  550 

hypertrophic  osteoarthropathy,  750 
Sector  splint,  140 
Seitliche  Ruckgratsverkrummong,  539 

Verbiegung,  539 
Semilunar  cartilages,  dislocation  of,  454 
Senile  coxitis,  379 

osteomalacia,  38 
Separation  of  epiphysis  in  infectious  osteomyelitis,  5 1 8 

of  tibial  tubercle,  450 
Sequestra,  211,  212,  277 
Sequestrum  formation,  71 
Sero-synovitis,  chronic,  of  hip,  377 
Serous  synovitis,  513,  514 

chronic,  of  knee,  442,  443 
Shaffer's  knee  splint,  429 

lateral  traction  splint,  774 

modification  of  Taylor's  ankle  splint,  359 
Sheath  of  psoas  muscles,  230 
Shiver  swansdown  plaster,  141,  356 
Shoe,  Sayre  club-foot,  141 

Scarpa  club-foot,  6,  141 
Shortening  of  tendo  Achillis,   193 
Shoulder,  congenital  dislocation  of,  880 
Shoulder-joint  disease,  476 
Sichelbein,  739 
Silicate  of  soda  splints,  161 
Silpi  sastri,  711 
Sinuses  in  elbow-joint  disease,  492 

in  hip-joint  disease,  320,  359 
Sitting  position,  balanced,  571 
Skin,  contractures  of,  50 
Skoliose  lordotische,  286 
Sling,  Barwell's,  142 
Snapping  knee,  460 
Spastic  contraction,  in  neuromimesis,  700 

paralysis,  649 

rigidity,  451 
Spellissy's  uniform   photographic   method   of  scolio- 
sometry, 566 
Spina  bifida,  16,  686 

ventosa,  75,  79,  503 
Spinal  abscesses,  table  of,  232 

accessory  nerve,  neurectomy  of,  196 

excurvation,  272 

palsy,  infantile,  97,  603 
Spinale  kinderlahmung,  603 
Spine,  actinomycosis  of,  277 

Adams'  method  of  examining,  243 

braces,  130,  139,  2S6,  591 

carcinoma  of,  278 

caries  of,  207 

gonorrhea  of,  277 

hyperesthetic,  244 

infectious  diseases  of,  277 

lateral  curvature  of,  539 

malignant  disease  of,  278 

neurasthenic,  244 

neuromimetic,  244 

normal  curves  in,  549,  550 

osteitis  of,  207 

osteomyelitis  of,  244,  277 

Pott's  disease  of,  207 

primary  curves  of,  550 

railway,  276 

sarcoma  of,  278 

secondary  curves  of,  550 

syphilis  of,  276: 

typhoid,  275      ' 
Spitzbuckel,  207,  272 
Spitzfuss,  795 
Splay-foot,  790 
Splicing  of  tendons,  176 


r 


93? 


INDEX. 


Splints,  celluloid,  158 

felt,  159 

leather,  163 

paper,  161 

plaster-of-Paris,  142,  425 

sector,  140,  435 

silicate  of  soda,  161 

stretcher,  349 

wood,  141,  162 
Spondylitis,  207,  295 

deformans,  244,  736 

scorbutic,  275 

traumatic,  276 
Spondyloarthrocace,  214 
Spondylolisthesis,  286,  287 
Spondylolisthetic  pelvis,  214 
Spondylolizemia,  213 
Spondylosis  articularis,  87 

rhizomelic,  281,  753 
Spontaneous  cure  of  deformity,  no,  117 

dislocation  in  suppurative  arthritis,  522 
of  hip,  402 
Sprains  of  ankle-joint,  472 

of  foot,  826 

of  wrist,  510 
Sprengel's  deformity,  486 
Spring-finger,  893 
Springs,  141 

flat-foot,  810 
Staphylococcus  aureus,  277 
Static  predisposition  toward  deformity,  62 

deformities,  19 

scoUosis,  547 
Sternomastoid,  tenotomy  of,  187 
Sternum,  absence  of,  289 

fissured,  289 

partial  development  of,  290 
Stillman's  sector  splint,  435 
Stirrups,  140 
Stockinet,  158,  159,  160 
Stopjoint,  140 
Storto  del  piede,  760 
Stretcher  splint,  349 
Stroking,  124,  630 
Stromeyer's  splint,  435 
Strumous  arthritis,  407 

diathesis,  209 

joint  disease,  59 
Studsguard's  method  for  excision  of  wrist-joint,  503 
Subcoracoid  bursitis,  481 
Subcutaneous  osteotomy,  10,  199 

tenotomy,  9,  10,  176 
Subdeltoid  bursitis,  480 
Subperiosteal  abscess,  51S 
Subscapular  bursitis,  481 
Subserrate  bursitis,  481 
Sun  parlors,  119 
Sunhght,  treatment  by,  119 
Superficial  pretibial  bursa,  449 
Superincumbent  weight  theory,  20 
Supernumerary  fingers  and  toes,  S84 
Suppurative  arthritis,  521 

acute,  of  knee,  446 

prepatellar  bursitis,  449 

subdeltoid  bursitis,  480 
SureMvation  congenitale  de  I'omoplate,  486 
Suspension  apparatus  of  Sayre,  157 

of  the  body,  6 

in  Pott's  disease,  253 

trolley,  of  Willard,  637 
Suspensory  cradle  of  Wolff,  576 
Suturing  of  nerves,  197 
Swansdown  plaster.  Shiver,  141,  356       "A 
Swedish  gymnastics,  120 


Swelling,  spindle-shaped,  492 

white,  59,  209,  407,  492,  501 
Symptomatic  intermittent  joint  hydrops.  515 
Syndactylism,  888 
Syndesmose,  56 
Syndesmolomy,  776 
Synostose,  56 

Synovial  type  of  elbow-joint  disease,  490 
Synovitis,  422,  513 

acute  serous,  513 

of  knee,  442 

chronic  purulent  of  knee,  407 

chronic  serous,  514 
of  knee,  443 

fungous,  310 

of  knee,  407 

in  elbow-joint  disease,  492 

in  infectious  osteomyelitis,  518 

leathery  crepitation  in,  515 

of  hip,  376 
Syphilis  hereditaire  tardiv,  747 
Syphilis  in  rickets,  717 

of  hip-joint,  381 

of  spine,  276 

tardy  hereditary,  of  bones,  747 
Syphilitic  osteoperiostitis,  526 

periostitis,  44 
Syringomyelia,   708 
System,  Sargent,  122 

Swedish,  120 

Zander,  122 


Tabes  dorsalis  spasmodique,  653 

Table  of  abscesses  in  sacro-iliac  tuberculosis,  29S 
of  course  of  abscess  in  hip-joint  disease,  318 
of  a  differential  diagnosis  of  Pott's  disease,  247 
of  frequency  of  lateral  curvature  of  spine,   540 
of  orthopedic  diseases,  91 
of  parts  affected  in  infantile  spinal  paralysis, 

613 

of  scoliosometry,  563 

of  spinal  abscesses,  232 
Talipe  equina,  795 
Talipes,  759 

acquired  valgus,  791 

arcuatus,  705 

artificial  calcaneus.  798 

calcaneus,  764,  796 

calcaneo-valgus,  804 

calcanco-varus,  804 

equina,  795 

equino-valgus,  803 

equino-varus,  799 
paralytica,  S03 

equinus,  763,  795 

plantaris,  S03 

valgus,  763,  790 

varus,  763,  7S9 
Tape,  lead,  98,  130,  564 
Tapotement,  124 
Tapping,  124 

Tardy  hereditary  syphilis  of  bones,  747 
Tarsectomy,  471,  777,  780,  821 
Tarsotomy,  777,  821 
Tarsus,  tuberculous  disease  of,  469 
Taylor's  convalescent  splint,  358 

method  of  reducing  deformity,  357 

modification  of  Davis's  spUnt,  354 

protection  splint,  452 

spine  brace,  256 
Tellerman-Sheffield  apparatus,  129 
Tenderness,  intra-articular,  417 


^ 


INDEX. 


Tendo  Achillis,  shortening  of,  193 

tenotomy  of,  182 
Tendon,  quadriceps  extensor,  rupture  of,  461 

shortening,  193,  641 

splicing,  176 

transplantation,  194,  485,  642 
Tendons,  contractures  of,  50 

dislocation  of,  904 

patellar,  rupture  of,  461 

rupture  of,  913 
Tenoplasty,  176,  178 
Tenorrhaphy,  176 
Tenotomes,  177,  179 
Tenotomy,  10,  176,  639,  746,  776,  821,  S72 

after-treatment,  190 

Anderson's  method,  176 

Bayer's  method,  177 

Billroth's  method,  360 

complications,  iSo 

methods,  176 

of  biceps,  188 

of  inner  hamstring,  184 

of  outer  hamstring,  188 

of  peroneal  tendons,  184 

of  plantar  fascia,  183 

of  sternomastoid,  187 

of  tendo  Achillis,  182 

of  tibialis  amicus,  183 

of  tibialis  posticus,  189 

repair  after,  178,  195 

Rugh's  method,  177 

subcutaneous,  9,  10,  176 

technic  of,  179 
Tenosynovitis  of  ankle-joint,  474 

of  wrist-joint,  505 
Tephromyelite  anterieure  aigue,  603 
Tephromyelitis,  603 
Theory,  amniotic,   19 

archioterigium,  16 

of  arrest  of  development,  16,  768,  844 

of  functional  pathogenesis  of  deformity,  20 

of  heredity,  15,  766,  840 

of  intrauterine  pressure,  15,  766,  S41 

of  maternal  impressions,  766 

of  mechanical  pressure,  15,  766,  S41 

of  prenatal  disease,  16,  767,  S43 

osseous,  17,  768,  844 

pressure,  20 

ray,  19 

superincumbent  weight,  20 

Volkmann-Huetter,  20 

Wolff's  law,  20,  23 
Thorax,  deformities  of,  289,  291 
Tibial  tubercle,  enlargement  of,  450 
fracture  of,  450 
separation  of,  450 
Tibialis  anticus,  tenotomy  of,  183 

posticus,  tenotomy  of,  189 
Toe,  crumpled,  37 

displacement  of,  829 

hammer,  37,  828 

lateral  deviation  of,  830 

overlapping,  37 
Tools,  orthopedic,  139 
Tophi,  535 
Torsion  of  vertebra^  in  movements  of  spine,  550 

in  scoliosis,  551 
TorticoUi,  6S7 
Torticollis,  68  7 

acquired,  688 

cicatricial,  690 

compensatory,  690 

congenital,  687 

diagnosis  of,  69a 


TorticolUs,  etiology  of,  687 
frequency  of,  687 
idiopathic,  690 

paralytic,  6S9  f 

pathology  of,  690 
prognosis  of,  693 

rheumatic,  688  ^ 

spastic,  689  /' 

symptoms  of,  691 
synonyms  of,  687 
tetanoid,  689 
traumatic,  688 
treatment  of,  694 
mechanical,  695 
nerve  operations,  6g6 
operative,  698 
therapeutic,  694 
Traction  in  treatment  of  joint  disease,  12 
Transformation,  law  of,  20 
Transplantation  of  nerves,  197 

of  tendons,  194 
Trauma  as  an  etiologic  factor  in  joint  disease,  44,  512 
Traumatic  arthritis,  519 
coxa  vara,  397 
cubitus  varus,  499 
deformities,  19,  44 
flat-foot,  474 
spondylitis,  276 
Traumatism,  904 

of  hip,  375      .  . 
Trephining  in  hip-joint  disease,  367 
Trichterbrust,  91 
Trigger  finger,  893 

joint,  140 
True  ankylosis,  56,  918 
Tubercle,  67,  413 
bacilli,  66 

inoculation  with,  65 
of  tibia,  enlargement  of,  450 
fracture  of,  450 
separation  of,  450 
Tubercular  diathesis  in  Pott's  disease    209 
Tubercule  tardif  a  evolution  rapide,  59 
Tuberculose  articulaire,   59,  407 
caries,  407 
chronique,  59,  407 
Tuberculosis,  latent,  61 
polyarticular,  63 

verrucose,  65  ,^. 

vertebral,  207 
Tuberculous  arthritis,  59 

disease  of  ankle-joint,  463 

abscess  in,  463,  464 
pointing  of,  464 
treatment  of,  467 
amputation  in,  468 
curetage  in,  467 

contraindications  for,  467 
definition  of,  463 
deformity  in,  464 

treatment  of,  466 
diagnosis  of,  465 

from  acute  articular  rheumatism, 


from  functional  affections,  465 

from  infectious  arthritis,  465 

from  sprains,  465 

from  tenosynovitis,  465 

from  tuberculosis  of  the  astragalus, 
464 
etiology  of,  463 

extension  of,  to  neighboring  joints,  463 
fixation  for,  466 
frequency  of,  463 


r 


r 


INDEX. 


iiberculous   disease   of   ankle-joint,    indications   for 
amputation  in,  46S 

for  operation  in,  467 
iodoform  injections  in,  466 
Kocher's  method  of  resection  in,  468 
mortality  from  resection  in,  467 
night  cries  in,  464 
pathology  of,  463 

primary  focus,  463,  464 
primary  synovial  origin  of,  463,  464 

osseous  origin  of,  463,  464 
prognosis  in,  465 

influence  of  age  on,  465 
resection  in,  467 
statistics  on,  468,  469 
swelling  in,  464 
symptoms  of,  464 
treatment  of,  466 

conservative,  466 

of  abscess,  467 

of  deformity,  466 

operative,  467 
of  astragalus,  470 
of  the  calcaneum,  470 
of  the  cuboid,  470 
of  elbow-joint,  490 

abscess  in,  491,  492 

aspiration  of,  494 

spontaneous  opening  of,  492 

treatment  of,  494 
age  in,  490 

ankylosis  in,  493,  494 
atrophy  in,  492 
deformity  in,  492 
fistulas  in,  492 
frequency  of,  490 
functional  results  in,  493 
limitation  of  motion  in,  492 
muscular  spasm  in,  492 
osseous  type  of,  490 
pathology  of,  490 
primary  focus  in,  490 
prognosis  in,  493 
resection  in,  495 

indications  for,  495 

statistics  on,  495 
sex  in,  490 
side  affected  in,  490 
sinuses  in,  492 
s^Tnptoms  of,  492 
syno^aal  type  of,  490 
synovitis  in,  492 
traumatism  in,  492 
treatment  of,  493 

amputation,  496 

arthrectomy,  495 

conservative,  493 

constitutional,  493 

curetment,  494 

immobilization,  493 

iodoform  emulsion,  494 

of  abscesses,  494 

of  fistulas,  494 

of  osseous  foci,  494 

of  sequestra,  494,  495 

passive  congestion,  494 

splints,  493,  494 
white  swelling  in,  V92 
of  the  hip, 
of  knee-joint, 
abscesses 

aspiration  of,  437 

frequency  of,  437 

spontaneous  opening  of,  %20,  437 


e  swelhng  in,  492 
P,  301  \ 

oint,  407  j 

esses  in,  419      7 


Tuberculous  disease  of  knee-joint,  abscesses  in,  treat- 
ment of,  437 

amputation  in,  440 

amvloid  disease  in,  421 

arthrectomy  in,  438 

arthritic  variety  of,  408 

caries  sicca  in,  420 

causes  of  death  in,  421 

chronicity  of,  407,  413 

definition  of,  407 

deformity  in,  415,  417 
causes  of,  416 
treatment  of,  433 

destruction  of  joint  in,  421 

diagnosis  of,  421 

diarrhea  in,  421 

differential  diagnosis  of,  422 

acute  infectious  epiphysitis,  423 
acute  rheumatic  arthritis,  422 
arthritis  deformans,  423 
Charcot's  disease,  423 
gonorrheal  arthritis,  422 
hemophilia,  423 
injury  to  knee-joint,  424 
neuromimesis,  424 
periarthritic  disease,  423 
sarcoma,  423 
suppurative  arthritis,  422 
synovitis,  422,  444 

erasion  in,  438 

etiology  of,  407 
age,  407 

exciting  causes,  408 
predisposing  causes,  408 

excision  in,  436,  439 

expectant  treatment  in,  437 

femoral  osteitis  in,  420 

femoral  variety  of,  407 

first  stage  of,  414 

deformity,  415 
disability,  414 
discoloration,  415 
general  condition,  416 
heat,  415 
lameness,  414 
limitation  of  motion,  415 
malaise.  414 
pain,  414 
swelling,  415 

fracture  of  femur  in,  436 

frequency  of,  407 

general  condition  in,  416,  419 

knock-knee  in,  414,  416 

luxation  in,  415 

mechanical  apparatus  for,  426 

meningitis  in,  421 

mortality  in,  440,  441 

night  sweats  in,  421 

onset  of,  414 

pathology  of,  408 

bone  infarct,  413 

primary  focus,  40S,  410,  413 

secondary  focus,  413 

primary  osseous  variety,  408,  410 

primary  synovial  variety,  408,  410 

prognosis  in,  424 

recover)'  from,  420 

resection  in,  439 

results  of  arthrectomy  in,  439 

results  of  resection  in,  440 

resume  of,  441 

second  stage  of,  417 

abnormal  movement  in,  4:7 
general  condition  in,  419 


■-> 


INDEX. 


341 


Tuberculous  disease  of  knee-joint,  second  stage  of, 
intra-articular  tenderness  in, 

417 
joint  crepitus  in,  417 
night  cries  in,  417 
pain  in,  417 

true  lengthening  in,  417 
true  shortening  in,  418 
separation  of  epiphyses  in,  436 
stages  of,  413 
subluxation  in,  414,  417 
symptoms  of,  413 

abnormal  movement,  417 

abscess,  419 

ankylosis,  419 

atrophy,  417 

deformity,  415,  417,  418 

disability,  414 

discoloration,  415 

grating,  417 

heat,  415 

joint  crepitation,  417 

knock-knee,  414,  416 

lameness,  414 

limitation  of  motion,  415 

luxation,  415 

malaise,  414 

muscular  spasm,  415 

night  cries,  417 

of  first  stage,  414 

of  second  stage,  417 

of  third  stage,  419 

pain,  414,  417 

pyrexia,  415.  419 

tenderness,  415 

subluxation,  415,  417 

swelHng,  415 
synonyms  for,  407 
termination  of,  407 
third  stage  of,  419 

abscess  in,  419 
ankylosis  in,  419 
joint  destruction  in,  419 
tibial  variety  of,  408 
treatment  of,  425 

ambulatory  traction  in,  434 

amputation  in,  440 

arthrectomy  in,  43S 

Bier's  method  of,  433 

Billroth  splint,  42S,  435 

caliper  knee  splint  in,  427 

cantharidal  collodion,  432 

carbolic  acid  in,  433 

compression  in,  432 

conservative,  425 

constitutional,  425 

counterextension  in,  434 

crutches  in,  426,  434 

erasion  in,  43S 

excision  in,  436,  439 

expectant,  437 

fixation  in,  425,  433,  437 

gradual  forcible  extension,  435 

Goldthwait's  genuclast  in,  436 

high  sole  in,  426,  434 

hydrogen  peroxide  in,  43S 

hygiene  in,  425 

injections  in,  43S 

iodoform  emulsion  in,  433,  438 

irrigation  in,  43S 

Lovett's  traction  splint  in,  434 

mechanical,  425 

nitric  acid  in,  438 

of  abscesses,  437 


Tuberculous  disease  of  knee-joint,  treatment  of  cq 
plications,  433 
of  deformity,  433 
of  sinuses,  43S 
ointments  in,  432 
operative,  438 

Paquelin  cautery  in,  432,  439 
passive  congestion,  433 
plaster-of-Paris  splints  in,  425J  433 
rapid  forcible  extension  in,  435 
recumbent  traction  in,  434 
redressement  force  in,  435 
resection  in,  439 
Robert's  splint  in,  430 
Sayre  knee  splint  in,  427 
Shaffer  splint  in,  429 
Stromeyer  splint  in,  435 
supplementary,  432 
supracondyloid  osteotomy  in,  436 
Taylor's  traction  apparatus  in,  434 
Thomas'  knee  splint  in,  426,  435 
tincture  of  iodin  in,  432 
tonics  in,  425 
traction  in,  434 
walking  splint  in,  432 
.r-ray,  432 

varieties  of,  407,  408 

white  swelling  in,  415 
of  the  metacarpals,  503 
of  the  metatarsals,  471 
of  the  phalanges,  471 
of  the  scaphoid,  470 
of  the  shoulder-joint,  476 
of  the  tarsus,  469 
of  the  wrist-joint,  500 

ankylosis  in,  502 

cause  of  death  in,  502 

etiology  of,  500 

fistula  formation  in,  501 

frequency  of,  500 

diagnosis  of,  501 

from  tenosynovitis  of  wrist,  507   , 

involvement  of  tendon-sheaths  in,  500', 

pathology  of,  500 

primary  types  of,  500 

prognosis  in,  501 

pulmonary  tuberculosis  in,  500,  501 

statistics  on,  500,  503 

symptoms  of,   501 

treatment  of,  502 

amputation  in,  503 

conservative,  502 

curetment  in,  502 

excision  in,  502,  503 

iodoform  emulsion  in,  502 

of  fistulas  in,  502 

of  flexion  deformity  in,  502 

of  suppuration  in,  502 

operative,  502 

partial  arthrectomy  in,  502 

passive  congestion  in,  502 

white  swelling  in,  501 
embolus,  211 
fistulas,  73 
hydrops,  310 
infiltration,  211 
joint  disease,  59 

age  in,  62,  94 

amputation  in,  89 

association  with  phthisis,  94 

atypical  varieties,  76 

avenues  of  infection,  64,  66 

carbolic  acid  in,  86 

counterirritation  in,  86 


f 


INDEX. 


iberculous  joint  disease,  diagnosis  of,  8i 
distribution,  63 
etiology  of,  59 
exanthemata  in,  62 
heredity,  60 
pathology  of,  66 
polyarticular,  63 
predisposing  causes,  60 
prognosis  of,  82 
radiotherapy  in,  82 
repair  of,  80 
sex  in,  63,  93 
traumatism  in,  61,  93 
treatment  of,  84 
lesions,  repair  of,  80 
osteomyehtis,  59 
ostitis,  59 

subdeltoid  bursitis,  480 
tenosynovitis  of  ankle-joint,  474 
of  wiist,  505 
Tumor  albus,  407 

Tumors,  congenital,  of  finger  and  toes,  895 
Typhoid  spine,  275 

U. 

Unilateral  development,  yii 
Universal  ball-and-socket  joint,  140 
Ununited  fractures,  912 
Urethral  fever,  syno\'itis  in,  513 
Uric  acid  deposits,  535 

V. 

Valleix's  painful  points,  29S 
Verrucose  tuberculosis,  65 
Vertebra,  absence  of,  290 
Vertebral  artjiritis,  207 

osteomyeUtis,  244 

tuberculosis,  207 
Vertical  osteotomy,  200 
Vestmentary  deformities,  29 

of  feet,  37 
Vibration,  123,  129 


Volkmann-Huetter  theory,  20 
Vorverbiegung  der  Wirbelsaule,  286 

W. 

Wax  models,  no 
Weakened  feet,  37 
Webbed  fingers,  888 

toes,  889 
Weigel-Hoffa  machine,  123 
White  swelling,  59,  209,  407,  492,  501 
Willard  hip-splint,  350 

irrigating  curette,  Barker-Willard,  205 

operation  for  hip  disease,  36S 

trolley  suspension  for  infantile  paralysis,  637 

wheel-chair  for  infantile  paralysis,  637 
Winkelforraige,  207,  272 
Wooden  corsets,  162,  255 

splints,  141,  162 
Wrenches,  club-foot,  172,  82 1 
Wringing,  124 
Wrist,  sprain  of,  510 
Wrist-joint  disease,  500 
Wry-neck,  3,  6,  219,  687 
Wyeth's  pins,  372 

X. 

X-Bein,  727 

X-ray  in  diagnosing  deformit\',  109,  234 
in  treating  tuberculous  joint  disease,  87 

Y. 

Young's  frame  for  applj-ing  spine  casts,  158 
tenotomes,  177 
wheel  couch,  142,  252 


Zamba  de  piemas,  739 
Zander  machine,  122 

system,  122 
Zweiwuchs,  715 


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